Evidence-based Review, Grade of Recommendation, and Suggested Treatment Recommendations for Melasma

Management of Melasma: Laser and Other Therapies-Review Study

Melasma is a commonly occurring pigmented skin condition that can significantly affect one's appearance, described as symmetric hyperpigmentation that presents as irregular brown to gray-brown macules on various facial areas, such as the cheeks, forehead, nasal bridge, and upper lip, along with the mandible and upper arms. Due to its complex pathogenesis and recurrent nature, melasma management is challenging and the outcomes following treatment are not always deemed satisfactory. Solely treating hyperpigmentation may prove ineffective unless paired with regenerative techniques and photoprotection, since one of the main reasons for recurrence is sun exposure. Hence, the treatment protocol starts with addressing risk factors, implementing stringent UV protection, and then treatment using different strategies, like applying topical treatments, employing chemical peels, laser and light therapies, microneedling, and systemic therapy. This review aims to provide a summary of the effectiveness and safety of the frequently employed laser and light therapies for treating melasma, focusing on laser therapy as a treatment for melasma.

Comparison of 755-nm picosecond alexandrite laser versus 1064-nm Q-switched Nd:YAG laser for melasma: A randomized, split-face controlled, 2-year follow-up study

OBJECTIVES

Pulsed laser treatment of melasma has shown some promising results. To compare the effectiveness and safety of 755-nm picosecond alexandrite laser (PSAL) fitted with diffractive lens array (DLA) versus 1064-nm Q-switched neodynimum:yttrium aluminum garnet laser (QSNYL) for the treatment of melasma.

METHODS

We conducted a randomized, split face controlled, 2-year follow-up study. Each face was divided into two parts, each side receiving three treatments with either PSAL or QSNYL at 1 month intervals. Modified Melasma Area Severity Index scores (mMASI), pain scores, patient satisfaction and adverse events were recorded. In vivo reflectance confocal microscopy (RCM) images were acquired.

RESULTS

Twenty subjects were enrolled and three dropped out. At 6 months, mMASI scores were significantly lower than baseline for QSNYL sides (p = 0.022), with no statistically significant difference between PSAL sides before and after treatment, PSAL sides versus QSNYL sides, or patient satisfaction scores. QSNYL treatment was associated with less pain (p = 0.014). No serious adverse events were reported. In the PSAL sides RCM showed a large number of dendritic melanocytes infiltrated in the dermis at 2 weeks and 4 weeks after treatment. Ten patients (58.82%) reported recurrence or exacerbation at 2-year follow-up with no statistically significant difference between the two lasers.

CONCLUSIONS

QSNYL demonstrated short term clinical efficacy for melasma, but did not provide any additional benefit compared to PSAL with DLA. QSNYL was associated with less pain. There was a high recurrence rate at 2-year follow-up. RCM allowed the detection of cellular changes in melasma lesions.

Expert consensus on perioperative integrated skincare for noninvasive energy-based device aesthetic procedures in clinical practice in China

BACKGROUND

Noninvasive energy-based device (NI-EBD) aesthetic procedures has recently gained widespread usage for treating various skin conditions, enhancing skin texture and performing rejuvenation-related procedures. However, practically all NI-EBD procedures result in variable degrees of damage to the skin barrier, inducing pathological and physiological processes such as oxidative stress and inflammation, and only a small percentage of individuals possess the innate ability to restore it.

OBJECTIVE

To introduce the concept of integrated skincare and establish standardized operational procedures for perioperative integrated skincare, and furnish a theoretical basis for clinical diagnosis and treatment performed by professional medical aestheticians.

METHODS

The author leveraged domestic and international guidelines, clinical practice expertise and evidence-based research, adapting them to suit the specific circumstances in China.

RESULTS

The consensus were provided four parts, including concept and essence of integrated skincare, integrated skincare significance during the perioperative phase of NI-EBD procedures, active ingredients and functions of effective skincare products, standardized perioperative skincare procedure for NI-EBD procedures and precautions. For the standardized perioperative skincare procedure, four recommendations were listed according to different stages during NI-EBD procedures.

CONCLUSION

These recommendations create the 'Expert Consensus on Perioperative Integrated Skincare for Noninvasive Energy-Based Device Aesthetic Procedures in Clinical Practice in China'.

Chemical Peels in Treatment of Melasma

Superficial chemical peels are one of the most popular skin resurfacing procedures in a dermatologists' clinic today due to quick application process, fast recovery, good patient acceptance, and excellent cosmetic results. The role of various peeling agents like glycolic acid, salicylic acid, trichloroacetic acid, Jessner's solution, retinoic acid, and lactic acid in the management of melasma has been established as that of an additional or maintenance therapy. This article details the current evidence and recommendations for the use of chemical peels in the treatment of melasma, a chronic and recurrent hyperpigmentary disorder.

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.

The Role of p16/Ki-67 Immunostaining, hTERC Amplification and Fibronectin in Predicting Cervical Cancer Progression: A Systematic Review

Human papillomaviruses (HPVs) are common sexually transmitted infectious agents responsible for several anogenital and head and neck cancers. Cervical cancer (CC) is the fourth leading cause of death in women with cancer. The progression of a persistent HPV infection to cancer takes 15–20 years and can be preventable through screening. Cervical cytology (Pap smear) is the standard screening test for CC and precancerous lesions. For ASC-US and ASC-H lesions, a combination of Pap smear and HR-HPV analysis is recommended as a triage step before colposcopy. However, these tests cannot predict progression to CC. For this purpose, we summarized current scientific data on the role of p16/Ki-67 immunohistostaining, telomerase and fibronectin in predicting progression to CC. p16 and p16/Ki-67 dual staining (DS) were more specific than HR-HPV DNA testing for the detection of CIN2+/CIN3+ in women with ASC-US and LSIL. Similarly, hTERC FISH analysis significantly improved the specificity and positive predictive value of HPV DNA testing in differentiating CIN2+ from CIN2 cytological samples. In conclusion, p16 IHC, p16/Ki-67 DS and hTERC FISH amplification are all valid adjunctive biomarkers which significantly increase the sensitivity and specificity of cervical dysplasia diagnosis, especially when combined with HPV DNA testing. However, considering the global socioeconomic background, we can postulate that p16 and p16/ Ki-67 IHC can be used as a next step after positive cytology for ASC-US or LSIL specimens in low-income countries, instead of HPV DNA testing. Alternatively, if HPV DNA testing is covered by insurance, p16 or p16/Ki-67 DS and HPV DNA co-testing can be performed. In middle- and high-income countries, hTERC amplification can be performed as an adjunctive test to HPV DNA testing in women with ASC-US and LSIL.

Clinical Assessment of a Circadian-based Antioxidant System Combined with a Comprehensive Brightening Serum in Diverse Subjects with Moderate to Severe Facial Hyperpigmentation

BACKGROUND

Hyperpigmentation conditions can affect all skin types but occur more frequently in darker skin. Because many factors have been implicated in the etiologies of these disorders, multi-targeted approaches may be required to achieve a better overall outcome in a diverse patient population.

AIMS

The purpose of this study was to investigate the safety and efficacy of a combination regimen of a comprehensive cosmetic brightening agent (LYT2) with a broad blend of antioxidants (LVS) to reduce hyperpigmentation and improve overall skin appearance.

METHODS

The combination of LYT2 and LVS, in addition to a basic skincare routine, was evaluated in subjects of either Caucasian or Asian (a majority of whom were Indian) descent, presenting with moderate to severe hyperpigmentation. Efficacy evaluations consisted of investigator clinical grading of overall hyperpigmentation, skin-tone evenness, and radiance, as well as subject self-assessment questionnaires.

RESULTS

Immediate and progressive improvement was noted by the investigators for all assessed parameters. At the end of the 12-week study, investigators observed a 45% mean decrease from baseline for overall hyperpigmentation. In addition, a 50% improvement in skin tone evenness and a 58% increase in radiance was observed. These investigator assessments were matched by good patient scores for self-perceived efficacy parameters and high overall satisfaction. One patient (7%) showed a treatment-related adverse event.

CONCLUSION

A combination skincare regimen that combines the pigmentation control of LYT2 with the broad antioxidant defense of LVS is a well-tolerated and effective treatment option to improve the appearance of facial hyperpigmentation and make skin more radiant.

Comparison of the Efficacy of Melasma Treatments: A Network Meta-Analysis of Randomized Controlled Trials

Background: Melasma is an acquired pigmentation disorder with challenges in treatment because of its refractory nature and high risk of recurrence.

Objectives: This study aimed to compare the efficacy and side effects of 14 common therapies for melasma using a systematic review and network meta-analysis (NMA).

Methods: The PubMed, Embase, and Cochrane Library databases were searched till December 2020 using the melasma area and severity index as a therapeutic index. A total of 59 randomized controlled trials (RCTs) met the inclusion criteria and were selected.

Results: The ranking of relative efficacy compared with placebo in descending order was Q-switched Nd:Yag 1,064-nm laser (QSND), intense pulsed light, ablative fractional laser (AFL), triple combined cream (TCC), topical vitamin C, oral tranexamic acid (oTA), peeling, azelaic acid, microneedles (MNs), topical tranexamic acid (tTA), tretinoin, picosecond laser, hydroquinone (HQ), and non-AFL. Moreover, QSND was more effective than HQ and tTA against melasma. The ranking of percentage (%) of side effects in ascending order for each of 14 therapies with more than 80 participants was tretinoin (10.1%), oTA (17.6%), HQ (18.2%), AFL (20.0%), QSND (21.5%), TCC (25.7%), tTA (36.75%), peeling (38.0%), and MN (52.3%). Taking both efficacy and safety into consideration, TCC was found to be the most favorable selection among the topical drugs for melasma. QSND and AFL were still the best ways to treat melasma among photoelectric devices. oTA as system administration was a promising way recommended for melasma. Among 31 studies, 87% (27/31) studies showed that the efficacy of combination therapies is superior to that of single therapy. The quality of evidence in this study was generally high because of nearly 50% of split-face RCTs.

Conclusions: Based on the published studies, this NMA indicated that QSND, AFL, TCC, and oTA would be the preferred ways to treat melasma for dermatologists. However, more attention should be paid to the efficacy and safety simultaneously during the clinical application. Most of the results were in line with those of the previous studies, but a large number of RCTs should be included for validation or update.

Systematic Review Registration: identifier: CRD42021239203.

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.

A split face randomized controlled trial comparing 1,064 nm Q-switched Nd-YAG laser and modified Kligman's formulation in patients with melasma in darker skin

BACKGROUND

No randomized studies compared the efficacy and safety of modified Kligman's triple combination (TC) with 1,064 nm Q-switched Nd-YAG laser (QSNYL) in melasma in darker skin.

OBJECTIVES

To compare the efficacy and safety of QSNYL and TC in the treatment of melasma in Fitzpatrick skin types IV and V.

METHODS

In this split face randomized controlled trial, participants' cheeks were randomized to receive either weekly QSNYL (group A) or daily TC (group B) for 12 weeks, followed by 12 weeks of follow-up.

RESULTS

Twenty-eight patients completed the intervention, and 21 of them completed follow-up. We found a significant but modest reduction in mean melanin index, modified Melasma Area Severity Index (MASI), and photographic and patient's assessment in both modalities (P < 0.01). No significant differences were detected between the groups. All patients had reappearance of pigmentation by the end of follow-up. Adverse reactions were significantly more in group B (P < 0.001).

LIMITATION

The desired sample size could not be achieved.

CONCLUSION AND RELEVENCE

No statistically significant differences were observed between QSNYL and TC as monotherapy in melasma. Reappearance of melasma is inevitable after stopping treatment.

Therapeutic efficacy and safety of oral tranexamic acid 250 mg once a day versus 500 mg twice a day: a comparative study

Oral tranexamic acid (TXA) 250 mg twice daily has been used effectively for 4 weeks to 6 months to treat melasma. As relapses are frequent on discontinuation, a minimum effective dose of TXA that can be used safely for long time remains unknown. We compared the efficacy of oral TXA 250 mg once daily and 500 mg twice daily given for 16 weeks in 132 (m:f 23:109) adults with melasma. 42 patients in Group-A (TXA 250 mg/d) and 46 patients in Group-B (TXA 500 mg twice/d) completed the study. They were followed up at 4-week interval for percentage reduction in baseline Melasma Area Severity Index (MASI) and at 24 and 28 weeks for relapse. Therapeutic response, for both as per-protocol and intention-to-treat analysis, was scored as very good (> 75% reduction), good (51-75% reduction), moderate (25-50% reduction), mild (< 25% reduction) or no improvement. Reduction in mean MASI score at 4 weeks was not statistically significant in Group-A but it decreased significantly 8 weeks onwards and was comparable with that in Group-B. The relapse rate was higher in Group-B (10.8%) than Group-A (4.7%) at the end of 28 weeks. Oligomenorrhoea and abdominal discomfort in few patients did not necessitate treatment discontinuation. TXA 500 mg twice daily showed early reduction in mean MASI score compared to 250 mg given once daily with comparable safety and therapeutic efficacy at 16 weeks. Open-label cross-sectional design, no control arm, small number of patients in each group, MASI score being subjective assessment tool, short duration of treatment and follow-up are study limitations.

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.

Randomized control trial outcomes of tranexamic acid combination serum as a depigmenting agent for the use in healthy individuals

To compare the effectiveness of tranexamic acid (TA) combination serum with hydroquinone, the gold standard in whitening agents for healthy populations. This was a three-arm randomized controlled trial. The subjects were divided into three groups: the first group received 3% TA combination serum (3% TA, 4% galactomyces ferment filtrate, 2% niacinamide, and 4% alpha arbutin), the second group received 2% TA combination serum, and the third group received 4% hydroquinone. One milliliter of each serum was applied on three holes: Hole A, which was located 4 cm from the left cubital fossa, Hole B, which was located 4 cm from the first hole, and Hole C, which was located 4 cm from the right cubital fossa. The skin brightness and pigmentation intensity were evaluated each week for 4 weeks using a chromameter. A total of 44 subjects were recruited for this study. All groups showed a significant improvement in skin brightness and pigmentation intensity after 4 weeks (p < .001). There were no differences between the treatment groups and hydroquinone (p > .05). TA serum (2 and 3%) combined with 4% galactomyces ferment filtrate, niacinamide, and alpha arbutin is an effective depigmenting agent.

Melasma and thyroid disorders: a systematic review and meta-analysis

BACKGROUND

Thyroid hormones may play a key role in melasma; however, melasma link with thyroid disorders remains controversial.

OBJECTIVES

To compare the serum levels of thyroid-stimulating hormone (TSH), T4, T3, anti-thyroid peroxidase (anti-TPO), and antithyroglobulin between patients with melasma and control group using meta-analysis.

METHODS

We screened 10 databanks and search engines, searched mesh and nonmesh terms. The identified evidences were reviewed and quality assessed using the Newcastle-Ottawa Scale (NOS). The heterogeneity between the primary results was investigated using Cochrane and I-square indices. Random effect model was applied to combine the standardized mean differences of thyroid function indicators between patients with and without melasma. P values meta-analysis was used to investigate the association between anti-TPO and melasma.

RESULTS

We included seven studies, 473 cases, and 379 controls that had been investigated. The total standardized mean differences (95% confidence intervals) of TSH, T3, T4, and antithyroglobulin antibody between cases and controls were estimated to be 0.33 (0.18, 0.47), -0.01 (-0.20, 0.19), -1.50 (-2.96, -0.04), and 0.62 (0.14, 1.11), respectively. The corresponding figures among women were 0.35 (0.17, 0.52), 0.10 (-0.17, 0.38), -2.75 (-6.30, 0.81), and 0.99 (0.14, 1.83), respectively. P value of meta-analysis showed a significant relationship between anti-TPO serum level and melasma (Fisher = 26.80, P = 0.020).

CONCLUSION

Serum levels of TSH, anti-TPO, and antithyroglobulin antibody were significantly higher in patients with melasma than those without melasma. Moreover, these differences were more severe among women with melasma.

New oral and topical approaches for the treatment of melasma

Melasma is a common, therapeutically challenging, and universally relapsing disorder of hyperpigmentation that is most often observed in women and individuals with Fitzpatrick Skin Types III through VI. The pathogenesis of melasma is complex and protean. Contributing factors that are often implicated in the etiopathogenesis of this condition include a genetic predisposition, intense ultraviolet radiation exposure, and hormonal influences. Therapeutic interventions for melasma include a multimodality approach incorporating photoprotection agents, topical and oral skin lighteners, and resurfacing procedures. Given our expanding knowledge of the pathogenesis of melasma, new and effective treatments are expanding our therapeutic armamentarium. This article reviews new and emerging oral and topical treatments for melasma.