Proposing Melasma Severity Index: A New, More Practical, Office-based Scoring System for Assessing the Severity of Melasma

Low-level laser therapy for skin rejuvenation: A safe and effective solution baked by data and visual evidence

BACKGROUND

Skin aging and photoaging is a process that may appear at a relatively early age, causing an aesthetic problem. Common signs of skin aging include wrinkles, dyspigmentation, and decreased elasticity.

AIM

Aim of this article is to study the effectiveness and safety of low-level laser therapy (LLLT) for skin rejuvenation.

METHODS

Thirty Syrian female patients aged 25-50 participated in this study and were diagnosed with moderate to severe melasma and wrinkles. The patients were divided into two groups and received LLLT with a wavelength of 660 nm emitting a continuous wave. The power density and dose used were 15.6 mW/cm2, and 3 J/cm2 respectively, and the laser effective area was 32 cm2. The evaluation was done before, during, and after 12 treatment sessions, based on photographs, in addition to the modified Melasma Area Severity Index (MASI), Pinch test, and Fitzpatrick's classification of facial wrinkling at baseline.

RESULTS

Comparing before, and after treatment, and between the two groups, revealed a significant improvement in skin rejuvenation, with a statistical significance (p < 0.05). Additional outcome measures included assessments of patient satisfaction scores, and no adverse effects or re-pigmentation were reported.

CONCLUSIONS

Our results suggest that LLLT may be a useful and safe therapeutic option in treating melasma, skin elasticity, and wrinkle improvement, which we advised to be integrated into treatment, and follow-up programs in cosmetics and dermatology.

Skin hyperpigmentation index in melasma: A complementary method to classic scoring systems

BACKGROUND

Due to relapsing nature of melasma with significant impact on quality of life, an objective measurement score is warranted, especially to follow-up the patients with melasma and their therapy response in a quantitative and precise manner.

AIMS

To prove concordance of skin hyperpigmentation index (SHI) with well-established scores in melasma and demonstrate its superiority regarding inter-rater reliability. Development of SHI mapping for its integration in common scores.

METHODS

Calculation of SHI and common melasma scores by five dermatologists. Inter-rater reliability was assessed by intraclass correlation coefficient (ICC) and concordance by Kendall correlation coefficient.

RESULTS

Strong concordance of SHI with melasma area and severity index (MASI)-Darkness (0.48; 95% CI: 0.32, 0.63), melasma severity index (MSI)-Pigmentation (0.45; 95% CI: 0.26, 0.61), and melasma severity scale (MSS) (0.6; 95% CI: 0.42, 0.74). Using step function for mapping SHI into pigmentation scores showed an improvement of inter-rater reliability with a difference in (ICC of 0.22 for MASI-Darkness and 0.19 for MSI-Pigmentation), leading to an excellent agreement.

CONCLUSION

Skin hyperpigmentation index could be an important additional cost-and time-conserving assessment method, to follow-up the patients with melasma undergoing brightening therapies in clinical studies, as well as in routine clinical practice. It is in strong concordance with well-established scores but superior regarding inter-rater reliability.

Tranexamic acid microinjections versus tranexamic acid mesoneedling in the treatment of facial melasma: A randomized assessor-blind split-face controlled trial

BACKGROUND

Melasma is a hyperpigmentary disorder causing cosmetic disfigurement. We aimed to compare the efficacy and safety of tranexamic acid (TXA) microinjections with TXA mesoneedling for facial melasma.

METHODS

This randomized assessor-blind split-face controlled trial included patients with symmetric facial melasma. One side of the face received TXA (100 mg/ml) mesoneedling and the other side intradermal TXA microinjections. The interventions were repeated three times with 4-week intervals (weeks 0, 4, and 8). The primary outcome was improvement in modified Melasma Area and Severity Index (mMASI) 4 weeks after the final treatment session. Secondary outcomes were complications and patient satisfaction with the treatments evaluated by a visual analog scale (VAS).

RESULTS

All 27 patients included in the study were female (mean age: 44.22 ± 8.39 years). Both groups were comparable in terms of mMASI scores before and after treatment (standardized mean difference [SMD] = 0.32, 95% confidence interval [CI] -0.22; 0.85, p = 0.248 and SMD = -0.13, 95% CI -0.66; 0.40, p = 0.633, respectively). The mMASI score change from baseline was not different (SMD = -0.39, 95% CI -0.93; 0.15, p = 0.157). However, patient satisfaction was significantly higher with TXA mesoneedling (SMD = 0.77, 95% CI 0.21; 1.32, p = 0.007). Post-inflammatory hyperpigmentation occurred in one patient in the TXA mesoneedling group. Erythema, scaling, and edema were significantly higher with TXA mesoneedling (p < 0.001).

CONCLUSIONS

TXA mesoneedling was comparable with TXA microinjection in the treatment of facial melasma, while patient satisfaction was significantly higher with TXA mesoneedling; however, the high frequency of complications occurring with this treatment should be taken into account.

Trichloroacetic Acid With Microneedling Versus Trichloroacetic Acid Alone for Treating Melasma

BACKGROUND

Melasma is a common acquired disorder of hyperpigmentation which is difficult to treat.

OBJECTIVE

We aim to evaluate the efficacy and safety of combined microneedling with trichloroacetic acid in the treatment of melasma.

PATIENTS AND METHODS

Forty women with facial melasma were included and randomly classified into 2 groups. Group A included 20 patients treated with bimonthly session of trichloroacetic acid 25% peeling (8 sessions) combined with a monthly session of microneedling (4 sessions). Group B included the other 20 patients that were treated by bimonthly trichloroacetic acid 25% peeling session (8 sessions) alone.

RESULTS

After 1 and 3 months of treatment, the mean melasma area and severity index, modified melasma area and severity index, and melasma severity index scores showed significant improvement in each group (p < .05 for each). At 1 and 3 months, the mean percentages of change of all scores were significantly higher in group A than group B (p < .05).

CONCLUSION

Combined trichloroacetic acid peel with microneedling is effective and a safe option for treating melasma.

The Comparison between Free Thyroxine and Thyroid-Stimulating Hormone Levels on Melasma Severity: A Cross-Sectional Study

Background: Melasma has been suspected to be linked with levels of thyroid hormone. There is no study that explains the association between thyroid hormone level with melasma severity. Objective: This study aims to find the discrepancies in the levels of thyroid hormone in varying severity of melasma by using two different measurement techniques. Methods: Subjects were chosen consecutively from the dermatology clinic at RSUPN Dr. Cipto Mangunkusomo hospital. Forty-eight patients participated in this study were categorized into mild melasma and moderate-severe melasma based on modified melasma area and severity index (mMASI) and Janus II measurement. Results: Statistically, mMASI measurement showed no significant association between varying melasma severity with levels of thyroid stimulating hormone and free T4 (FT4), P 0.375 and P 0.208, respectively. The Janus II examination using polarized light modality has a weak positive correlation with the serum FT4 level (r=0.3; P 0.039). Weak correlation was also found between the two measurement strategies, Janus II and mMASI (r= 0.314; P 0.03). Conclusion: There are no significant differences observed in levels of thyroid hormone between subjects with varying degrees of melasma severity.

A split face comparative study between intradermal tranexamic acid and Erbium-YAG laser in treatment of melasma

BACKGROUND

Although there are different treatment modalities of melasma, it remains a challenging problem. Erbium-YAG laser proved its efficacy in melasma improvement with minimal downtime. Tranexamic acid (TA) is a new promising treatment of melasma.

OBJECTIVE

The first objective is to compare between the efficacy of intradermal injection of TA and Erbium-YAG laser in the treatment of melasma. The second objective is to use the dermoscope as an objective evaluation method.

PATIENTS AND METHODS

A split face study was conducted on 28 patients. One side of the face received intradermal TA injection. The other side was treated with laser. Melasma Area and Severity Index (MASI) and the dermoscope were used for evaluation of treatment.

RESULTS

The MASI scores showed a significant decrease in TA treated side. The dermoscope assessment showed no significant difference in both treatment modalities.

CONCLUSION

A promising results were obtained by both intradermal TA and Erbium:YAG laser; however, the TA yields a higher patient satisfaction because of its high efficiency and low cost.

Treatment of Refractory Melasma in Asians With the Picosecond Alexandrite Laser

BACKGROUND/OBJECTIVES

The picosecond Alexandrite laser was studied in our practice with the diffractive lens array and the flat optic to treat melasma.

METHODS AND MATERIALS

Sixty patients with melasma were treated in a prospective investigation with the picosecond Alexandrite laser. Nineteen patients were treated with the flat optic and 41 patients were treated with the diffractive lens array. Treatments were performed with 1 pass at 2-week intervals for 6 treatments. The Melasma Severity Index (MSI) was used to evaluate the patients before treatment and 3 and 6 months after the final treatment session.

RESULTS

At 6 months after the last treatment, there was an 18.5% difference between the groups with a 75.7% improvement in the MSI in patients with the diffractive lens array and a 57.2% improvement in the MSI score in patients with the flat optic. At 6 months, there was recurrence of melasma in 5% of the cases with no hyperpigmentation with the diffractive optic in contrast to recurrence in 16% of the cases in the flat optic group and a transient macular hyperpigmentation in 21% of the cases.

CONCLUSION

This investigation highlights the utility of a picosecond Alexandrite laser with a flat and diffractive lens to successfully treat a large percentage of Asian patients in a sunny climate.

Postinflammatory and rebound hyperpigmentation as a complication after treatment efficacy of telangiectatic melasma with 585 nanometers Q-switched Nd: YAG laser and 4% hydroquinone cream in skin phototypes III-V

BACKGROUND

The potential efficacy of vascular component-targeted laser has been evaluated for the treatment of melasma, which commonly found with the co-existence of telangiectasia.

AIMS

To evaluate the treatment efficacy and safety of 585-nm QSNYL and 4% HQ cream combination vs 4% HQ cream alone for telangiectatic melasma in the skin phototypes III-V.

PATIENTS/METHODS

Twenty-one Thai female patients with telangiectatic melasma and Fitzpatrick skin phototypes (FPTs) III-V were randomly treated with the 585-nm QSNYL on one side of the face for five sessions at 2-week intervals. All patients were assigned to apply HQ cream daily at night on both sides of the face for 10 weeks and a broad-spectrum sunscreen regularly throughout the study. The treatment efficacy and safety were evaluated using the Modified Melasma Area and Severity Index (mMASI), biometric evaluation, patient assessment, and adverse effects.

RESULTS

The combination-treated side yielded more significant improvement of mMASI than the topical-treated side at weeks 2, 4, and 8, respectively. However, 19% of the patients developed postinflammatory hyperpigmentation (PIH) on the laser-treated side, especially in FPTs IV-V and rebound hyperpigmentation. There was a significant improvement of hemoglobin and melanin index, but without statistical difference between the two treatment groups.

CONCLUSIONS

The combination of 585-nm QSNYL and HQ treatment yields treatment efficacy and skin rejuvenation effects for telangiectatic melasma. Nonetheless, a high incidence of PIH and rebound hyperpigmentation is adversely developed in dark FPT. Thus, this laser treatment should be cautiously applied in those with dark FPTs IV-V to avoid laser-induced pigment alteration.

Internalized stigma: One of the main factors responsible for the psychosocial burden of melasma?

BACKGROUND

Internalized stigma is the acceptance of negative stereotypes about the disease created by society and withdrawing self from society with emotions such as worthlessness and shame.

AIMS

This study aimed to investigate the internalized stigma state of patients with melasma, and to identify the factors affecting the internalized stigma.

METHODS

A total of 55 melasma patients were included. The sociodemographic and clinical characteristics of the patients were recorded. Melasma Severity Index, the Turkish version of the Melasma Quality of Life Scale (MelasQoL-TR), and Internalized Stigma Scale (ISS) were used. Besides, patients answered the Perceived Health Status (PHS) and the General Health Questionnaire 12 scales (GHQ-12) surveys.

RESULTS

The mean ISS total score was found as 49.49 ± 13.15. Cronbach's alpha coefficient for the whole scale was calculated as 0.92 for melasma patients. There was a significant correlation between the ISS total score and MelasQoL-TR (r = 0.608, P < .001). Besides, statistically significant positive correlations were also found between the overall scores of ISS and GHQ-12 (r = 0.578, P < .001). Linear regression analysis revealed that the most important determinant of internalized stigma was MelasQoL-TR (β = 0.313, P < .001).

CONCLUSIONS

This study demonstrates that patients with melasma internalize the negative stereotype judgments of the society about the disease. High levels of internalized stigma are related to poor quality of life and psychological illnesses. Therefore, internalized stigma may be one of the main factors responsible for the psychosocial burden of melasma.

A New 675 nm Laser Device in the Treatment of Melasma: Results of a Prospective Observational Study

Objective: This study evaluates the efficacy and safety of a new 675 nm laser source system on melasma. Background: Melasma is an acquired circumscribed hyperpigmented disorder that has a negative impact on patients' life quality. Different treatments are currently available. This study evaluates this new 675 nm laser source system, on melasma with the use of established parameters that guarantee minimum pain, the absence of side effects, and simplifying posttreatment management. Materials and methods: A total of 25 subjects (all women, 21-50 years old), with facial melasma and Fitzpatrick skin types I-III, were treated with three sessions of a new 675 nm laser system. Efficacy of treatment was evaluated using Melasma Severity Index (MSI) score before and 3 months after the last session. The appearance of side effects has also been monitored to evaluate safety. A preclinical study was executed to evaluate laser effectiveness on sheep skin. Results: All 25 subjects treated with the 675 nm laser had significant improvement in melasma according to MSI score (mean baseline MSI 26.4 ± 19.2; mean 3-month follow-up MSI 17.3 ± 15, p: 0.003). Histology in preclinical study showed selective damage of melanin-rich areas. No side effects have been observed except some minor erythematous reactions in two patients. Conclusions: Due to its high affinity with melanin, and its minimal interaction with the vascular component, novel 675 nm laser may be considered promising when treating benign pigmented lesions with a low risk of side effects and simple posttreatment management.

Intradermal Tranexamic Acid Injection for the Treatment of Melasma: A Pilot Study with 48-week Follow-up

BACKGROUND: Despite being an effective treatment for melasma, there have been limited reports on the long-term efficacy of intradermal tranexamic acid (TA) injection. OBJECTIVE: This study sought to evaluate the 48-week efficacy of a 4mg/mL intradermal TA injection for the treatment of melasma. METHODS: Five female patients with melasma participated in the 48-week follow-up after receiving 4-mg/mL intradermal TA injections on the face every two weeks for seven sessions and a sunscreen prescription. Assessments were performed at baseline and Weeks 4, 8, 12, 16, and 48 using the modified Melasma Area Severity Index (mMASI) score, melanin index, and patient satisfaction score. Safety and adverse effects were also evaluated. RESULTS: The mean (standard deviation) age of patients was 53.6 (8.14) years and Fitzpatrick Skin Type IV (60%) and Fitzpatrick Skin Type V (40%) were observed. The mean (standard deviation) duration of melasma was 7.6 (2.51) years and 60 percent of participants reported a family history of melasma. There was a significant decrease in mMASI score and melanin index at 16 weeks, without a statistically significant improvement of mMASI score at 48 weeks. Melasma recurrence was observed in 60 percent of the participants, with higher mMASI scores recorded, but the severity remained less than at baseline. The patient satisfaction score was lower from Week 16 to Week 48. Interestingly, a statistically significant decrease in the melanin index was observed up to Week 48, with no serious adverse effects. CONCLUSION: The 4-mg/mL intradermal TA injection yields significant efficacy at Week 16; however, melasma recurrence occurred during the 48-week follow-up. In addition to tranexamic acid injections, maintenance therapy and sun protection should be considered for patients with melasma.

Efficacy of microneedling plus topical 4% tranexamic acid solution vs 4% hydroquinone in the treatment of melasma: A single-blind randomized clinical trial

BACKGROUND

There are various treatment modalities for melasma, but none of them are effective on dermal component of melasma.

AIMS

In this study, we decided to evaluate the efficacy of microneedling plus tranexamic acid in comparison with 4% hydroquinone in the treatment of melasma.

METHODS

This is a single-blind randomized clinical trial on 70 participants with 14% dropout, and therefore, 60 patients with melasma completed the study. Patients were randomized based on simple randomization in 2 groups of A (microneedling plus topical 4% tranexamic acid, monthly) and B (topical 4% hydroquinone, nightly). Evaluation of mean MASI score, patient and physician assessments was performed at 4th, 8th and12th weeks of the treatment. Statistical analysis was performed by paired t test, chi-square test and Fisher's exact test, respectively.

RESULTS

Sixty women (30 patients in each group) were completed the study. Mean MASI score in group A was significantly lower at the end of the treatment (6.84 ± 4.31) than at the baseline (12.89 ± 5.16) (P < .01). Mean MASI score in group B was significantly lower at the end of the treatment (7.16 ± 4.38) than at the baseline (13.56 ± 4.88) (P < .01). There was no statistical difference between 2 groups regarding MASI score, physician and patient assessments during the treatment. Percentage of patient satisfaction was significantly higher than physician satisfaction in both treatment groups (P < .01).

CONCLUSION

In our study, the combination of microneedling with tranexamic acid did not differ from 4% hydroquinone in the treatment of melasma.

Association between heterozygote Val92Met MC1R gene polymorphisms with incidence of melasma: a study of Javanese women population in Yogyakarta

Introduction: Melasma is an acquired hypermelanosis of the face. The pathogenesis of melasma is multifactorial and may be caused by interactions between genetics and the environment. Research has shown that skin pigmentation is regulated by the Melanocortin-1 Receptor gene (MC1R). In Japanese populations, Val92Met and Arg163Gln genotypes of MC1R gene polymorphisms are associated with freckles and lentigo solaris, because they have skin types II–III, but for Indonesians who are skin type IV, hyperpigmentation disorders are often melasma.

Purpose: This study aimed to identify the association between Val92Met and Arg163Gln genotypes of MC1R gene polymorphisms with the incidence of melasma in a Javanese women population.

Patients and methods: This study used unmatched case-control design, conducted by clinical examination and questionnaire. Data were analyzed with Chi-squared test and Odds Ratio (OR).

Results: This study evaluated 158 Javanese women from 18–60 years old with 79 case and 79 control subjects. The genotype of Val92Met was found more common in melasma subjects than in non-melasma (p=0.005) with (OR2.53; 95% CI:1.21–5.29). By using a bivariate test we showed sun exposure and family history of melasma were risk factors for melasma (OR:1.99; 95% CI:1.04–3.78) and (OR:35.32; 95% CI:10.25–121.70). However, genotype of Arg163Gln was not a risk factor for the incidence of melasma (OR: 0.86; 95% CI:0.39–1.89).

Conclusion: The findings showed Val92Met genotypes, sun exposure and family history were risk factors for melasma incidence. This is the first study on incidence of melasma in an Indonesian population and contributes to ongoing efforts to understand the mechanisms of melasma.

The Management of Melasma on Skin Types V and VI Using Light Emitting Diode Treatment

OBJECTIVE

This study investigated light emitting diode (LED) treatment for patients with melasma on darker skin types.

BACKGROUND

Melasma is a common disfiguring skin condition in women which is difficult to treat and is refractory. The cause of melasma remains unclear.

METHODS

In this study, 60 female participants aged between 25 and 60 years, who presented with melasma, were enrolled (n = 39.85). They were purposely assigned to two groups according to their skin types. Both groups received a total of 36 LED light treatments over a period of 9 months.

RESULTS

Both subjective and objective results indicated a significant improvement of melasma. Statistical analyses revealed significant improvements in both groups.

CONCLUSIONS

The results of this study suggest that LED is effective in managing melasma. These results will provide a basis for future therapeutic use of phototherapy to improve melasma.