The effect of melasma on self-esteem: A pilot study

A randomized, controlled, split-face, double-blind comparison of a multimodality pigment-correcting serum containing lotus sprout extract versus hydroquinone for moderate to severe facial hyperpigmentation, including melasma, in a diverse population

Background

Hyperpigmentation results in uneven skin tone, with darker skin types disproportionately affected.

Objective

Assess efficacy and safety of a novel, hydroquinone (HQ)-free, multimodal pigment-correcting serum (Advanced Brightening Treatment [ABT]) versus 4% HQ in moderate to severe hyperpigmentation, including melasma.

Methods

In this split-face study, ABT and 4% HQ were applied topically on randomly assigned facial sides twice daily for 12 weeks. Hyperpigmentation, skin tone evenness, modified Melasma Area and Severity Index (mMASI), Melasma Quality of Life Questionnaire (MelasQoL), self-assessment questionnaires, and tolerability were assessed.

Results

Subjects (n = 113; melasma subgroup, n = 44) were Asian (22%), Black/African American (27%), Hispanic (22%), and White/Caucasian (28%). ABT achieved comparable results to 4% HQ. ABT was well tolerated and resulted in improvement versus baseline at all visits in mean overall hyperpigmentation (-11.7% at week 12; P ≤ .001), skin tone evenness (-8.8%, P ≤ .005), and, in the melasma subgroup, mMASI (-50.6%; P ≤ .011) and MelasQoL scores (33.0 vs 46.6 for week 12 vs baseline, respectively; P ≤ .011), with similar results across racial subgroups. ABT was preferred over 4% HQ, with high satisfaction rate (≥89%).

Limitations

Quality of life improvements per treatment were not evaluated separately.

Conclusion

Efficacy and safety of ABT is comparable to 4% HQ in individuals with facial hyperpigmentation, including melasma, across multiple racial/ethnic backgrounds.

Efficacy and safety of novel topical pigment-correcting regimen with biweekly diamond tip microdermabrasion procedures on facial hyperpigmentation

BACKGROUND

Facial hyperpigmentation can negatively affect an individual's emotional and psychosocial well-being.

AIMS

Assess safety and tolerability of a combination of microdermabrasion (DG) procedures using a novel brightening pro-infusion serum (EC-DG) with a targeted at-home treatment regimen in subjects with mild to severe facial hyperpigmentation, including melasma, post-inflammatory hyperpigmentation, and dark spots.

PATIENTS/METHODS

This 12-week, open-label study enrolled 18 subjects (Fitzpatrick skin types I-IV) who underwent 6 in-office DG procedures with EC-DG (one procedure administered biweekly), along with daily topical application of a brightening treatment serum and dark spot cream. End points included change from baseline across multiple skin quality attributes and the Melasma Area and Severity Index (MASI), self-assessment questionnaires, and tolerability assessments.

RESULTS

The combination treatment was well tolerated and resulted in significant (p ≤ 0.05) improvements from baseline in radiance, tactile roughness, and moisturization/hydration immediately after the first treatment, in MASI score at day 3, and in overall hyperpigmentation at week 4. Most (94.1%) subjects were satisfied with treatment.

CONCLUSIONS

DG procedures using EC-DG combined with a targeted at-home skincare regimen are effective and tolerable for treating facial hyperpigmentation across a broad range of skin types.

The aggressive face of melasma: unveiling the influence of upper lip pigmentation on social perception

Introduction

Although melasma leads to emotional distress and quality-of-life reduction, indigenous cultures practice female facial tattooing. Facial cues influence personality trait inferences and attractiveness ratings. Skin lesions have been shown to alter gaze patterns, emotion perception, and social evaluations.

Aim

This study aimed to evaluate melasma's impact on visual attention, perceived attractiveness, and social evaluations, considering distinct anatomical areas. Additionally, we sought to compare perceptions of traditional facial tattoos due to their purposeful placement.

Material and methods

Gaze fixation patterns were examined via eye-tracking, and image-based personality questionnaires were completed for psychological trait assessment. Visual stimuli showcased anatomic melasma variants and tattoo patterns.

Results

Traditional tattoos often follow midline patterns, sparing the upper lip. Both melasma and tattoos significantly affected visual attention (p < 0.001), with chin and upper lip melasma garnering increased attention. Upper lip melasma decreased gaze to the ocular area (p ≤ 0.002). while increasing perioral fixations (p < 0.001) compared to healthy faces. Upper lip tattoos conveyed increased perceived aggressiveness (p = 0.004). Ratings for attractiveness and personality traits were lower for centrofacial melasma than other variants, with no significant difference between centrofacial and isolated upper lip melasma.

Conclusions

The global avoidance of upper lip pigmentation underscores its perceptual burden. Upper lip pigmentation directs gaze towards anger-signalling regions, increasing perceived aggression and reducing attractiveness. Centrofacial melasma's impact parallels an isolated upper lip pattern, underscoring the disproportionate role of upper lip pigmentation. These findings warrant considering upper lip melasma's significant influence when evaluating quality of life and establishing treatment goals.

Characteristics of dermal vascularity in melasma and solar lentigo

BACKGROUND /PURPOSE

Melasma and solar lentigo (SL) are major benign hyperpigmented lesions, and both have been shown to involve the dermal vasculature. This review discusses current knowledge regarding the clinical characteristics of dermal vascularity in melasma and SL, as well as the results of relevant molecular biological investigations.

METHODS

PubMed and Google Scholar were searched in December 2023 to identify articles related to melasma, SL, and the dermal vasculature in these lesions.

RESULTS

Vascular morphologies in melasma and SL have been detected by histological and non-invasive methods, including modalities such as optical coherence tomography. Biological studies have indicated that factors secreted from vascular endothelial cells, such as stem cell factor and endothelin-1, can promote melanogenesis. With respect to phototherapy, blood vessel-targeting laser treatments are expected to provide long-term suppression of pigmentation, but this regimen is only effective when dilated capillaries are visible.

CONCLUSION

In both melasma and SL, clinical and experimental investigations are revealing the contributions of dermal vascularity to hyperpigmentation. More effective treatment may require identification of hyperpigmentation subtypes. In the future, knowledge of treatment (including phototherapy) is expected to accumulate through reliable and validated non-invasive measurements.

Efficacy and safety of metformin for melasma treatment: a systematic review and meta-analysis

Objective: Metformin has recently been demonstrated to have an anti-melanogenic activity. Nevertheless, clinical evidence of the effectiveness of metformin in melasma is lacking. The objective of this study was to assess the efficacy and safety of metformin in the treatment of melasma. Methods: MEDLINE, Embase, PubMed, Cochrane Library (CENTRAL), Scopus, CINAHL, and grey literature databases were searched to 4 October 2022 and updated on 26 February 2023. Randomized controlled trials (RCTs), quasi-RCTs, observational studies, case series, and case reports investigating the efficacy and safety of metformin for melasma were included. The Melasma Area Severity Index (MASI) scores that changed from baseline were pooled using fixed-effects model and expressed as standardized mean differences (SMDs) and 95% confidence intervals (CIs). Results: Three RCTs including 140 patients with melasma were included. The results demonstrated that after 8 weeks, 15% topical metformin significantly reduced the Melasma Area Severity Index (MASI) score compared to placebo (1 trial; n = 60; MD, -0.56; 95% CI, -1.07 to -0.04; p = 0.034). Furthermore, when compared to triple combination cream (TCC), 30% topical metformin demonstrated similar efficacy in reducing the MASI score after 8 weeks (2 trials; n = 80; MD, 0.19, 95% CI, -0.25 to 0.63; p = 0.390). Patients using 30% topical metformin had fewer adverse events compared to TCC users, although no statistical difference was found. Conclusion: Topical metformin was as effective as triple combination cream (TCC) in decreasing changes in the MASI score in patients with melasma, with minimum adverse events. Further studies with larger sample sizes, longer follow-up times, and well-designed trials are required. Systematic Review Registration: Identifier PROSPERO (CRD42022351966).

Melasma in people with darker skin types: a scoping review protocol on prevalence, treatment options for melasma and impact on quality of life

BACKGROUND

Melasma is one of the most encountered dermatoses in dermatology and skin care clinics. It is a challenging chronic, recurrent condition associated with hyperpigmentation. Its aetiology is poorly understood. Melasma affects all races and gender but is more prevalent in women with darker skin types. Being a facial lesion, melasma has a severe impact on quality of life due to its disfigurement. While many modalities of treatment for melasma exists, unfortunately, effectiveness and safety remain a huge concern. Treatment modalities are variable and often unsatisfactory. The objective of this scoping review is to systemically map available evidence from literature regarding melasma on people with darker skin types, garner insight as to how melasma affects the quality of life and begin to investigate and gain understanding on effectiveness of different treatments used for melasma.

METHODS

A scoping review guided by Arksey and O'Malley's framework, the enhancements and recommendations of Levac, Colquhoun and O'Brien, Daudt and associates and the 2015 Johanna Briggs Institute's guidelines will be conducted. Systematic electronic searches of databases and search engines will include Scopus, PubMed, CINAHL Complete, Cochrane, Science Direct, and Web of Science which will be conducted to attain published peer-reviewed articles of all study designs excluding reviews and grey literature. All literature that meets the inclusion criteria, research question and sub-question will be included in this review. All the retrieved literature will be exported to an Endnote X20 library. Quality appraisal of the included articles will be conducted using the mixed methods appraisal tool (MMAT) 2018 version.

DISCUSSION

We anticipate mapping relevant literature on the melasma, investigating the effectiveness of treatment options of melasma as well as evaluating its association with quality of life in people with darker skin types. This study is likely to reveal research gaps, which could guide future implementation research on melasma treatment interventions.

SYSTEMATIC REVIEW REGISTRATION

This protocol has been registered a priori with OSF and is accessible on this link: https://osf.io/ru3jc/ .

Azelaic Acid Versus Hydroquinone for Managing Patients With Melasma: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Melasma, a commonly acquired hyperpigmentation skin condition, is usually treated with topical agents as the first line of management. This systematic review and meta-analysis aimed to assess the efficacy and safety of azelaic acid versus hydroquinone in treating melasma patients. We conducted a comprehensive search across four online databases (PubMed, Scopus, Web of Science, and Cochrane Library) from the time of their creation until May 28, 2023. We considered randomized controlled studies comparing hydroquinone with azelaic acid for the treatment of melasma patients. We used the Cochrane Risk of Bias tool 2 to evaluate the risk of bias. The mean difference (MD) for continuous variables and the risk ratio (RR) for categorical variables, with a 95% confidence interval (CI) were pooled. Six studies were included, with a total of 673 patients with melasma. The azelaic acid had a lower mean change in melasma area severity index (MASI) than the hydroquinone group [MD= -1.23, 95% CI (-2.05, -0.40), P=0.004]. No difference was observed regarding the improvement via the objective response scale, the reduction in pigmentation, or the adverse events reported. However, despite not being statistically significantly different, there was a trend towards having more good responses in the azelaic acid group. Azelaic acid may be better than hydroquinone in reducing melasma severity (measured by MASI). However, larger studies with long-term follow-up are needed to validate these findings.

Hydroquinone cream-based polymer microneedle roller for the combined treatment of large-area chloasma

Melasma is a common hyperpigmented skin condition that occurs on the face and other areas prone to light exposure, seriously affecting people's quality of life. Microneedle, a new type of transdermal drug delivery device, can significantly improve skin permeability. In this study, we designed and fabricated a polymer microneedle roller (PMR) using a mold hot pressing method, and established a mouse model of melasma induced by ultraviolet radiation. The dynamometer and insertion test of MNs into parafilm and skin of mice indicates that the MNs have sufficient mechanical properties to insert parafilm and skin of mice. The two methods (apply hydroquinone cream (HQC) directly and pre-treat with PMR before applying HQC) were used to treat melasma. From the results of skin surface observation, determination of superoxide dismutase (SOD) activity and malondialdehyde (MDA) content in skin and liver tissues, histological observation, and skin Optical coherence tomography (OCT), we confirmed both the two methods had a therapeutic effect while the PMR pretreatment group exhibited a better therapeutic effect. In addition, there were statistical differences between the UV group (P < 0.05). Together these results indicated that the MNs may be promising in future clinical applications in improving the UV irradiation-induced pigmentation like melisma.

Self-Esteem, Depression, Anxiety and Quality of Life in Patients with Melasma Living in a Sunny Mediterranean Area: Results from a Prospective Cross-Sectional Study

INTRODUCTION

Melasma is a common acquired disorder of hyperpigmentation and has a significant effect on quality of life. The aim of this prospective cross-sectional study was to assess the effect of melasma on depression, social anxiety and self-esteem in the Greek population.

METHODS

The study included a total of 254 participants: 127 patients with melasma and an equal sample of healthy controls. Both participant groups completed the following psychometric measures: the Hospital Anxiety and Depression Scale (HADS) to assess anxiety and depression and Rosenberg's Self-esteem Scale (RSES) for self-esteem. Furthermore, in patients with melasma, quality of life was assessed using Melasma Quality of Life (MELASQoL).

RESULTS

Melasma patients (7.47 ± 4.53) presented statistically significantly higher anxiety compared to healthy controls (6.06 ± 3.59, p = 0.006), while no differences emerged with regard to depression or self-esteem. It is important to note that the difference regarding anxiety remained significant (b = 1.25, p = 0.003) even after adjusting for age, depression and self-esteem. A higher disease severity (MASI) correlated statistically significantly with longer disease duration (r = 0.24, p < 0.001), higher depression (r = 0.28, p = 0.002), and a more impaired health-related quality of life (MelasQol; r = 0.29, p < 0.001). Notably, a more impaired health-related quality of life was also correlated with higher depression (r = 0.19, p = 0.027) and lower self-esteem (r = - 0.31, p < 0.001).

CONCLUSION

The results of this study highlight the importance of evaluating quality of life, anxiety and depression in patients with melasma. The therapeutic approach should not be based solely on clinical findings; it should also include an evaluation of the patient's psychological aspects. Dermatologists can further improve their patient care by being supportive or requesting psychological intervention when needed, resulting in better compliance with treatment and an improved social and psychological status.

A randomized controlled clinical trial to evaluate safety and efficacy of a Unani formulation in the management of Kalaf (Melasma)

OBJECTIVES

Kalaf (Melasma) is an acquired facial hypermelanism. It has direct impact on patient's quality of life and leads to development of various personality disorders. Lack of effective treatment and recurrences have drawn the attention of researcher to find alternative treatment. This study aimed to evaluate safety and efficacy of a topical Unani formulation in the management of melasma.

METHODS

We conducted a prospective randomized controlled clinical study on the participants diagnosed with melasma. The participants (n=72) randomized into test (n=36) and control (n=36) groups. Sixty participants (n=30 in each group) completed the duration of therapy. The participants of the test group were treated with a classical Unani formulation and control group with hydroquinone 4%. The primary end point was change in mean MASI score and secondary end point was improvement in quality of life after eight weeks of treatment.

RESULTS

The Unani formulation reduced 40.5% mean MASI score (17.31 ± 9.58 to 10.28 ± 5.92) in comparison to 32% reduction in mean MASI score (20.58 ± 9.49 to 13.92 ± 7.38) in the control group after eight weeks of treatment. When comparing with baseline the difference in MASI score was found statistically significant in both groups (p<0.05). On intergroup comparison, the change in MASI score between both groups was not statistically significant (p>0.05). In addition, MQOL and DQLI also improved significantly in both groups.

CONCLUSIONS

This study concluded that the Unani formulation and the control drug were equally effective and safer in the management of melasma.

A combination treatment of drug-laser-photon for melasma: A retrospective study of clinical cases

BACKGROUND

Combinational therapy such as taking tranexamic acid while using laser treatment has been proved potential efficacy by many experiments. However, there is few research which contains large samples and consistent observations.

OBJECTIVE

We evaluated clinical efficacy and safety of a new systemic treatment of drug-laser-photon therapy.

METHODS

Retrospective and randomized investigator-blinded study of 75 patients with mixed type melasma was analyzed. At each visit, standardized photographs were taken using VISIA. Modified melasma area and severity index (mMASI) scores were marked using photographs by two dermatologists.

RESULTS

The mMASI score decreased significantly from 6.92 to 3.84 after the treatment. The VISIA analyze right cheek data shows: Spots (from 49.67 ± 3.43 to 56.09 ± 3.31), UV spots (from 41.39 ± 24.45 to 44.56 ± 25.86), and Brown spots (from 23.97 ± 17.89 to 28.16 ± 21.28) are statistically increased (p = 0.035, p = 0.018, p = 0.07). All patients feel varying degrees of improvement, about 10.17% felt very much improved, 30.51% felt much improved (51%-75%), 45.76% felt moderately improved (26%-50%), and 13.56% felt little improved (1%-25%).

LIMITATIONS

This study was no control group.

CONCLUSION

The efficacy and safety profile of the combination of drug-laser-photon therapy systemic treatment in melasma patients has been proved. It has potential possibility to become a new, reliable, widely suitable therapy strategy.

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.

Intradermal Injection of 100mg Tranexamic Acid Versus Topical 4% Hydroquinone for the Treatment of Melasma: A Randomized, Controlled Trial

Objective

Melasma is an acquired and chronic hyperpigmentation disorder associated with a negative impact on patients' quality of life. This study compares the efficacy of 100mg/mL intradermal TA with 4% topical HQ on female patients presenting with melasma lesions.

Methods

In this randomized double-blind controlled trial, 48 women with melasma were allocated into two groups, treated with either 100mg/mL intradermal TA or topical 4% HQ. The MASI (Melasma Area and Severity Index) score was assessed by paired t-tests and repeated measured ANOVAs. The Dynamic Physician General Assessment (PGA) was also performed by taking photographs with a digital camera.

Results

The average MASI score for the HQ and TA groups was 7.7 (3.0 SD) and 5.9 (2.5 SD), respectively. In both groups, the MASI decreased significantly after three months of treatment; however, the decrease was not significant between the two groups (P=0.1). All participants developed mild degrees of burning pain in the injection site without serious adverse effects.

Limitations

First, we only used the MASI score to measure melasma degree. Second, this is a single-center study with a small sample size. Third, the before-after photos were not taken with a high-quality camera.

Conclusion

The results of our study showed that both TA and continuous HQ significantly reduced the MASI score of patients without any significant differences and serious side effects. Although many treatment modalities are available for melasma, this condition is still challenging for dermatologists with a high recurrence rate after treatment.

Melasma: The need for tailored photoprotection to improve clinical outcomes

BACKGROUND/PURPOSE

Melasma is a frequent photoexacerbated hyperpigmentary disorder, which can significantly impact on the quality of life. We sought to review the pathogenesis of melasma, and the role of photoprotection in the prevention and treatment of this disorder.

METHODS

We conducted a narrative review of the literature. We performed literature searches with PubMed from January 1990 to December 2021 using the keywords "melasma," "pathogenesis," "ultraviolet radiation," "visible light," "photoprotection," and "sunscreens."

RESULTS

The physiopathology of melasma includes a complex interaction between genetics, sex hormones, and sun exposure. Visible light, in particular high-energy visible light (HEVL), and long-wave UVA (UVA1) play a key role in melasma pathophysiology, and recent research suggests that melasma shares many features with photoaging disorders. Melasma disproportionately affects dark-skinned individuals. Some 30% to 50% of South Americans and Asians, among other ethnicities, can present with melasma. Dark-skinned patients take fewer photoprotective measures. Also, the majority of melasma patients do not adequately follow photoprotection recommendations, including the application of sunscreen. Intensive use of a broad-spectrum sunscreen can prevent melasma in high-risk individuals, can lessen melasma severity (associated or not with depigmenting agents), and can reduce relapses.

CONCLUSIONS

Due to the physiopathology of melasma, sunscreens should be broad-spectrum with high sun protection factor, and provide high protection against UVA1 and VL. Sunscreens should be cosmetically acceptable and leave no white residue. Tinted sunscreens are an excellent choice, as pigments can protect from HEVL and UVA1, and may provide camouflage, but they must offer colors that match the skin tone of each patient.

Pigmentation control in pregnancy-induced melasma: Clinical assessment of a non-hydroquinone, non-retinol pigment-correcting serum

BACKGROUND

Melasma is an acquired disorder that results in irregular brown patches on the skin that can occur due to hormonal changes. Although pregnancy-induced melasma is usually temporary, it can become a chronic condition, with significant negative impact on quality of life (QoL).

AIMS

Determine the efficacy and tolerability of a topical, non-hydroquinone, non-retinol pigment-correcting serum (LYT2) for the treatment of pregnancy-induced melasma.

METHODS

This 12-week, single-center clinical trial enrolled 34 non-pregnant women who developed mild to severe facial melasma following a previous pregnancy (mean age, 42 years). LYT2 was applied twice daily to facial skin for 12 weeks in addition to a basic skincare regimen. Outcomes included changes from baseline in skin physiology parameters, such as brightness (L*), using objective digital image analysis, investigator-rated Overall Hyperpigmentation scale, Global Improvement, and Melasma Area and Severity Index (MASI), as well as subject-assessed Melasma Quality of Life Scale. Subjects also completed a questionnaire on self-perceived efficacy and attributes of the study product. Tolerability was assessed by the investigators (erythema, scaling, and edema) and subjects (burning/stinging and itching). Clinical assessments were conducted at baseline and Weeks 4, 8, and 12.

RESULTS

LYT2 provided statistically significant reductions in overall hyperpigmentation scores as early as Week 4 (-5.8% change from baseline) and continued through Week 12 (-14.6% change from baseline; all p < 0.001). Significant improvements in MASI scores and QoL were also achieved following LYT2 treatment, which was well tolerated.

CONCLUSIONS

LYT2 represents a new efficacious alternative to hydroquinone-based treatments for pregnancy-induced melasma.

Topical Treatments for Melasma and Their Mechanism of Action

OBJECTIVE

We conducted a review of topical agents currently used in melasma, discussing their mechanism of action, efficacy, safety, and tolerability, with an update on newer treatments.

METHODS

A systematic review from PubMed database was performed, using PRISMA guidelines. The search was limited to English and Spanish studies that were double or single blinded, prospective, controlled or randomized clinical trials, reviews of literature, and meta-analysis studies.

RESULTS

348 studies were analyzed; 80 papers met inclusion criteria. Triple combination (TC) therapy and hydroquinone (HQ) are still the most well-studied agents with strong evidence-based recommendation. TC therapy remains the gold standard of care based on efficacy and patient tolerability. Evidence has shown ascorbic acid, azelaic acid, glycolic acid, kojic acid, salicylic acid, and niacinamide to be effective as adjuvant therapies with minimal side effects. Tranexamic acid (TA) and cysteamine have become recent agents of interest due to their good tolerability, however more trials and studies are warranted. Less evidence exists for other topical agents, such as linoleic acid, mulberry extract oil, rucinol, 2% undecylenoyl phenylalanine, and epidermal growth factors agents.

LIMITATIONS

Some studies discussed represented a low sample size, and there is an overall lack of recent studies with larger populations and long-term follow up.

CONCLUSIONS

TC therapy continues to be the gold standard of care. Topical cysteamine and TA are newer options that can be incorporated as adjuvant and maintenance treatments into a patient's regimen. Cysteamine and topical TA have no known severe adverse effects. Evidence comparing other topical adjuvant treatments to HQ, maintains HQ as the gold standard of care.

A tiered approach for evaluation of anti-melanogenic activity of trans-N-coumaroyltyramine derivatives

Skin hyperpigmentation is commonly treated by topical drug application. Several naturally occurring compounds exhibit attractive biological effects including anti-melanogenic activity. Chemically modified derivatives of those compounds are expected to be more efficient. However, efficacy and safety testing processes are of significant consideration to identify the most effective compound among them. Herein, we demonstrated a tiered approach to investigate the antipigmentation activity of 17 trans-N-coumaroyltyramine derivatives. First, we evaluated the in chemico antityrosinase activity, then the cytotoxicity of the most potent derivatives using a mitochondrial activity-based assay, followed with the in vitro anti-melanogenic activity in two dimensional (2D) monolayer human melanocytes. The selected derivatives were topically applied on a three dimensional (3D) pigmented-reconstructed human epidermis (pRhE) containing melanocytes and keratinocytes to evaluate their depigmenting activity. Two of the 17 derivatives displayed a significant reduction in pigmentation in the 3D pRhE, comparable to kojic acid, a known tyrosinase inhibitor. In addition, a molecular docking experiment indicated an interaction of the three derivatives and tyrosinase, suggesting that these derivatives have potent anti-melanogenic activity through tyrosinase inhibition. Our findings provide an alternative approach for investigating skin-whitening agents, thereby facilitating the research and development of skin-whitening products that need not be tested on animals.

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.

Misconceptions of photoprotection in skin of color

Terrestrial sunlight is the portion of electromagnetic radiation that is emitted by the sun and reaches Earth's surface. It encompasses 3 major components: UV radiation (290-400 nm), visible light (400-700 nm), and infrared radiation. The deleterious effects of UV radiation have been appreciated for decades, particularly among those with light skin tones (Fitzpatrick skin types I-II) who primarily manifest with burns of varying degrees of severity with sun exposure. In recent years, studies have increasingly shown the negative impact of visible light on skin health, particularly in individuals with skin of color (Fitzpatrick skin types IV-VI), including the exacerbation of hyperpigmentation disorders such as melasma and post-inflammatory hyperpigmentation, as well as induction of the former. Recommendations from medical societies and the US Food and Drug Administration for photoprotection have been evolving along with the knowledge base. Yet, misconceptions about skin damage related to sunlight and the benefits of photoprotection (particularly among those with Fitzpatrick skin types V-VI) are still prevalent among both clinicians and patients. Among patients with skin of color, disorders of hyperpigmentation and other consequences from sun exposure have been associated with impaired skin health and negative burden on quality of life. This review summarizes currently available evidence of the impact of both UV and visible wavelengths and the low utilization of photoprotection measures among people with skin of color, with the goal of providing recommendations to help educate patients.

In search of lost beauty: Experiences of Iranian women with melasma

BACKGROUND

The skin condition called melasma affects patients' appearance significantly and affects them psychologically and emotionally, besides leading to an impaired body image.

AIM

Since access to quality information in different cultural environments is necessary to understand the psychological problems associated with melasma, the aim of this qualitative study was to explore the experiences of 20 Iranian women with melasma.

PATIENTS/METHODS

The content analysis method was employed for this study. Twenty participants were selected through purposive sampling, and data were collected through face-to-face in-depth interviews and then transcribed verbatim.

RESULTS

After categorizing the initial codes, 14 subthemes were identified, which were classified under five themes-camouflage, seeking treatment, lost beauty, grief, and others' reaction; these were then grouped under a general one, "in search of lost beauty."

CONCLUSIONS

Melasma has a tremendous impact on the lives of the women it affects, and therapists should focus on the condition's social and psychological aspects, in addition to treatment.

The Vascular Component of Melasma: A Systematic Review of Laboratory, Diagnostic, and Therapeutic Evidence

BACKGROUND

Melasma is a common acquired disorder of hyperpigmentation, classically manifesting as symmetric brown patches on the face. Although the exact pathogenesis is not fully understood, vascular abnormalities have been implicated in melasma.

OBJECTIVE

To evaluate the laboratory and clinical evidence regarding the safety and efficacy of antivascular agents for the treatment of melasma.

METHODS

A systematic review of PubMed, EMBASE, and Cochrane was conducted on May 13, 2020, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Original research articles investigating the role of vascularity and/or evaluating the use of antivascular therapeutics in melasma were included. Clinical recommendations were based on the American College of Physicians guidelines.

RESULTS

A total of 34 original research articles as follows were identified: 4 laboratory studies, 15 diagnostic studies, and 15 therapeutic studies.

CONCLUSION

There is promising evidence supporting the use of tranexamic acid and laser/light therapies to treat the vascular component of melasma, and more rigorous clinical trials are needed to validate their efficacy. Clinicians may consider treatment with one or more antivascular therapeutics in patients with melasma. Further research is warranted to characterize the role of cutaneous vascularization in melasma and may provide insights for novel therapies.

Treatment of melasma: a review of less commonly used antioxidants

Melasma, a common cause for seeking dermatologic care, is a chronic condition of skin hyperpigmentation. With a poorly understood pathogenesis, and no universal cure, melasma is a challenge for many dermatologists. For decades, there has been investigation into the role of oxidative stress in melasma. In this literature review, we introduce the role of oxidative stress in melasma and discuss the function of various topical and oral antioxidant therapies for patients suffering from melasma. Numerous studies have shown efficacy of various antioxidant therapies for treatment of hyperpigmentation, and in this review, we focus primarily on those with less widespread use. Vitamin E, niacinamide, polypodium leucotomos, pycnogenol, grape seed extract, amino fruit acids, phytic acid, zinc, silymarin, Korean red ginseng powder, plant extracts, and parsley all have well-demonstrated evidence of antioxidant properties, and these substances have been studied in the context of skin hyperpigmentation. Although there is conflicting evidence of their therapeutic efficacy, the use of these naturally occurring substances is promising for patients and medical providers seeking alternative therapeutic options.

Melanogenic Inhibition and Toxicity Assessment of Flavokawain A and B on B16/F10 Melanoma Cells and Zebrafish (Danio rerio)

Excessive production of melanin implicates hyperpigmentation disorders. Flavokawain A (FLA) and flavokawain B (FLB) have been reported with anti-melanogenic activity, but their melanogenic inhibition and toxicity effects on the vertebrate model of zebrafish are still unknown. In the present study, cytotoxic as well as melanogenic effects of FLA and FLB on cellular melanin content and tyrosinase activity were evaluated in α-MSH-induced B16/F10 cells. Master regulator of microphthalmia-associated transcription factor (Mitf) and the other downstream melanogenic-related genes were verified via quantitative real time PCR (qPCR). Toxicity assessment and melanogenesis inhibition on zebrafish model was further observed. FLA and FLB significantly reduced the specific cellular melanin content by 4.3-fold and 9.6-fold decrement, respectively in α-MSH-induced B16/F10 cells. Concomitantly, FLA significantly reduced the specific cellular tyrosinase activity by 7-fold whilst FLB by 9-fold. The decrement of melanin production and tyrosinase activity were correlated with the mRNA suppression of Mitf which in turn down-regulate Tyr, Trp-1 and Trp-2. FLA and FLB exhibited non-toxic effects on the zebrafish model at 25 and 6.25 µM, respectively. Further experiments on the zebrafish model demonstrated successful phenotype-based depigmenting activity of FLA and FLB under induced melanogenesis. To sum up, our findings provide an important first key step for both of the chalcone derivatives to be further studied and developed as potent depigmenting agents.

Catamenial Hyperpigmentation: A Review

BACKGROUND: Changes in skin pigmentation patterns related to the fluctuation of estrogen receptors and progesterone receptors during menstruation, also known as catamenial hyperpigmentation, have been reported in several studies. OBJECTIVE: We sought to summarize the literature on catamenial skin hyperpigmentation and menses-induced exacerbations of skin pigmentation disorders. METHODS: We searched PubMed/MEDLINE and the Cochrane Skin database with the search terms menses and pigment, estrogen and pigment, progesterone and pigment, and hyperpigmentation and menses, then assessed the relevant literature on skin diseases related to nonpathological menstruation. RESULTS: The most commonly reported primary catamenial hyperpigmentation disorders are postinflammatory hyperpigmentation (PIH) after laser therapy and ultraviolet sensitivity (UV). The most reported chronic skin pigmentation exacerbated by menses is melasma. The literature detailing catamenial hyperpigmentation is limited to cross-sectional studies, experimental studies, surveys, review articles, case reports, and small trials, leading to a lower level of evidence. CONCLUSION: Our review of the literature revealed that the most common catamenial hyperpigmentation is melasma. We also found a reported higher risk of PIH after laser therapies and UV sensitivity. Estrogen and progesterone are two of the major factors responsible for catamenial hyperpigmentation of the skin. Generally, the changes happen in the luteal phase of the menstrual cycle when the serum levels of sex hormones are at their peak. Although the exact balance of influence is controversial, most recent studies indicate that estrogen has a more prominent role than progesterone in inducing hyperpigmentation.

Melasma Treatment: An Evidence-Based Review

BACKGROUND

Melasma is an acquired, chronic pigmentary disorder predominantly affecting women. It may significantly affect quality of life and self-esteem due to its disfiguring appearance. Multiple treatments for melasma are available, with mixed results.

OBJECTIVE

The aim of this article was to conduct an evidence-based review of all available interventions for melasma.

METHODS

A systematic literature search of the PubMed electronic database was performed using the keywords 'melasma' and/or 'chloasma' in the title, through October 2018. The search was then limited to 'randomized controlled trial' and 'controlled clinical trial' in English-language journals. The Cochrane database was also searched for systematic reviews.

RESULTS

The electronic search yielded a total of 212 citations. Overall, 113 studies met the inclusion criteria and were included in this review, with a total of 6897 participants. Interventions included topical agents, chemical peels, laser- and light-based devices, and oral agents. Triple combination cream (hydroquinone, tretinoin, and corticosteroid) remains the most effective treatment for melasma, as well as hydroquinone alone. Chemical peels and laser- and light-based devices have mixed results. Oral tranexamic acid is a promising new treatment for moderate and severe recurrent melasma. Adverse events from all treatments tend to be mild, and mainly consist of skin irritation, dryness, burning, erythema, and post-inflammatory hyperpigmentation.

CONCLUSIONS

Hydroquinone monotherapy and triple combination cream are the most effective and well-studied treatments for melasma, whereas chemical peels and laser- and light-based therapies are equal or inferior to topicals, but offer a higher risk of adverse effects. Oral tranexamic acid may be a safe, systemic adjunctive treatment for melasma, but more studies are needed to determine its long-term safety and efficacy. Limitations of the current evidence are heterogeneity of study design, small sample size, and lack of long-term follow-up, highlighting the need for larger, more rigorous studies in the treatment of this recalcitrant disorder.

Meanings of quality of life for patients with facial melasma

Objective: To exhibit the meanings attributed to quality of life by patients with facial melasma. Methods: Qualitative research using the focal group technique, with 10 people with facial melasma from a public hospital and private clinic of a municipality in the interior of the state of São Paulo. The methodological indicative used was content analysis. Results: In the interviewees’ speech, one perceives the annoyance generated by the opinion of others, with curious and even malicious questions related to the blemish. There is difficulty to hide the injuries and the appearance of skin neglect is also cause for distress for the participants. Conclusion: Because it affects the face, which makes it easily visible, melasma is uncomfortable and has a negative impact on the quality of life, since it affects patients’ psychological and emotional well-being.

Significados da qualidade de vida para pacientes com melasma facial

Objective: To exhibit the meanings attributed to quality of life by patients with facial melasma. Methods: Qualitative research using the focal group technique, with 10 people with facial melasma from a public hospital and private clinic of a municipality in the interior of the state of São Paulo. The methodological indicative used was content analysis. Results: In the interviewees’ speech, one perceives the annoyance generated by the opinion of others, with curious and even malicious questions related to the blemish. There is difficulty to hide the injuries and the appearance of skin neglect is also cause for distress for the participants. Conclusion: Because it affects the face, which makes it easily visible, melasma is uncomfortable and has a negative impact on the quality of life, since it affects patients’ psychological and emotional well-being.