Efficacy and safety of the combination of oral tranexamic acid and intense pulsed light versus oral tranexamic acid alone in the treatment of refractory Riehl's melanosis: A prospective, comparative study

BACKGROUND

There is no standardized and effective treatment modality for Riehl's melanosis.

AIMS

To compare the efficacy and safety of oral tranexamic acid (TXA) combined with intense pulsed light (IPL) versus TXA alone in the treatment of refractory Riehl's melanosis.

METHODS

A prospective study of 28 subjects with refractory Riehl's melanosis and Fitzpatrick Skin Types III or IV was conducted. All subjects received oral TXA 500 mg daily and 11 of them were treated in combination with monthly IPL therapy for 6 months. The primary outcome measure was mean melanin index (MI), erythema index (EI) and acquired dermal macular hyperpigmentation area and severity index (DPASI). The Physician Global Assessment (PGA) and patient satisfaction scale were documented.

RESULTS

After treatment, DPASI, mean MI, and EI were significantly reduced in both groups. The group treated with combination therapy showed better improvement according to MI (p = 0.0032) and DPASI (p = 0.00468). PGA and patient satisfaction scale showed superior efficacy in the combination group. No significant difference was observed in treatment-related side effects.

CONCLUSION

The combination of oral TXA and IPL proves to be a safe and satisfactory treatment strategy for refractory Riehl's melanosis.

Hyaluronic acid dissolving microneedle patch loaded with tranexamic acid for melasma treatment

Melasma is an acquired hypermelanotic condition characterized by the presence of irregular light-to-dark brown macules that primarily manifest on the sun-exposed areas of the skin, particularly the face. The management of melasma poses significant challenges, as it is often recalcitrant to treatment and tends to recur despite successful treatment. In this study, we explored a safe, easy, and effective melasma treatment strategy. A hyaluronic acid (HA)-based microneedle (MN) patch loaded with tranexamic acid (TXA) was designed to deliver the necessary medication for melasma treatment. The MN patch features uniform needles with adequate mechanical strength and effective penetration and solubility in the skin without cytotoxicity. Remarkably, these MNs substantially reduce the thickness of the epidermis of melasma mice, curtail melanin production, and diminish dopachrome tautomerase (DCT) expression.

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.

Best practices in the treatment of melasma with a focus on patients with skin of color

BACKGROUND

Melasma is a chronic hypermelanosis of the skin that affects approximately 1% of the global population, predominantly affects women, and is more prevalent in skin of color. Melasma is a common driver for patients with skin of color to seek out a dermatologist for treatment, and ensuring the right approach for these patients is important because some treatments may be associated with adverse side effects. Because of the chronicity of the disease and established psychosocial and emotional impacts, there is a large need to ensure care follows the best available evidence on the treatment of patients with melasma.

OBJECTIVE

Here, we summarized current available topical treatments for melasma with considerations dermatologists should have for their patients with skin of color.

METHODS

Steering committee consensus on clinical best practices.

RESULTS

We describe a flexible and focused treatment algorithm that reflects both treatment and maintenance periods that is a consensus of our extensive clinical experience.

LIMITATIONS

Use of real-world evidence and potential for individual practice bias.

CONCLUSION

Melasma can be challenging to treat, particularly in patients with skin of color, and our recommendations for best practices for patients in the United States are an important step toward standardizing care.

The role of 755-nm alexandrite picosecond laser in melasma management

Melasma is a skin dyspigmentation condition that disproportionately affects women, particularly those of Latino, Black, and Asian ethnicities, significantly impacting their quality of life. Efforts to identify effective treatment options have led to the exploration of picosecond laser technology which utilizes brief pulse durations to break down pigment while minimizing thermal damage to surrounding tissue. The 755-nm alexandrite picosecond laser, currently FDA approved for benign pigmented lesion removal, including melasma, is a promising solution. We aim to assess the efficacy and safety of the 755-nm alexandrite picosecond laser both as a stand-alone treatment for melasma and in combination with topical agents. We conducted a PubMed search using "755-nm picosecond" AND "melasma," "755-nm picosecond" AND "hydroquinone," and "755-nm picosecond" AND "tranexamic acid." English-written studies examining this laser as monotherapy or in combination with the topical agents were included. Those not meeting the criteria or lacking data related to melasma improvement were excluded. Monotherapy with the 755-nm picosecond laser led to a 50-75% improvement in melasma appearance in 40% of participants and a significant reduction in the average Melasma Area and Severity Index (MASI) score (p < 0.001) in all patients of one study. Notably, the use of topical tranexamic acid (TTA) in conjunction with the picosecond laser exhibited the most significant degree of improvement in hemi-MASI scores compared to the laser monotherapy group at one- and three-months post-treatment (p < 0.05). Patient satisfaction was also significantly higher for the combination group (p < 0.05). In contrast, combining hydroquinone (HQ) with the picosecond laser demonstrated no significant difference in outcomes compared to HQ alone, both of which were less effective than TTA with picosecond laser. The combination of the 755-nm picosecond laser with TTA proves promising, outperforming both laser monotherapy and laser with HQ. While monotherapy with the picosecond laser or topical agents is effective, literature favors combination therapy, especially the 755-nm picosecond laser with TTA, for superior benefits and minimal side effects. Ultimately, individualized regimens, considering factors like skin type, should be prioritized, given the heightened risk of postinflammatory hyperpigmentation, especially in skin of color patients.

Expression of Endothelin-1, Endothelin Receptor-A, and Endothelin Receptor-B in facial melasma compared to adjacent skin

Background/Objectives

Although melasma is highly prevalent, its pathogenesis is not yet fully understood. In the skin, endothelin-1 (ET-1) is primarily produced by keratinocytes in response to UVB exposure, which is mediated by an increase in IL-1α or reactive oxygen species. ET-1 plays a role in melanogenesis by binding to specific receptor B (ERB) or receptor A (ERA). However, the expression of ET-1, ERA, and ERB in melasma has not been systematically investigated. The objective of this study was to evaluate the expression of ET-1, ERA, and ERB in facial melasma compared to the adjacent unaffected skin.

Methods

Cross-sectional study, with 40 skin samples (20: facial melasma; 20: adjacent unaffected skin) from women with facial melasma without treatment for 30 days except for sunscreen. A triple staining immunofluorescence technique was performed for anti-vimentin, DAPI, plus one of the following antibodies: (a) anti-ET1, (b) anti-ERA; (c) anti-ERB. Interfollicular areas on the slides of each topography (melasma; unaffected skin) were photographed in triplicate under confocal laser microscopy. The mean staining intensities of the image histograms (0-255 pixels intensity) were estimated for different types of cells (suprabasal keratinocytes, basal layer, and upper dermis) and were blindly compared between topographies.

Results

The mean (SD) age of the participants was 44.9 (9.2). The expression of ET-1 was increased in the whole epidermis with melasma when compared to the adjacent skin, being 32.8% (CI95% 14.7%-52.6%) higher in the spinous layer (p=0.013), 30.4% (CI95% 13.7%-47.9%) higher in the basal layer (p=0.014), and 29.7% (CI95% 11.4%-49.7%) higher in the melanocytes (p=0.006). There was no noticeable expression of ET-1 within the cells on the upper dermis. Neither ERA nor ERB resulted in differential epidermal expression between melasma and unaffected skin (p≥0.1).

Conclusion

ET-1 is expressed more intensely on the epidermis from the skin with facial melasma compared to the unaffected adjacent skin.

Amber photobiomodulation versus tranexamic acid for the treatment of melasma: protocol for a double-blind, randomised controlled trial

INTRODUCTION

Photobiomodulation (PBM) has been suggested as an alternative treatment for melasma. In vitro studies have shown PBM with amber light inhibits the tyrosinase enzyme, induces autophagy and reduces the melanin content, but randomised controlled clinical trials are still needed. This study aims to evaluate the efficacy of amber PBM (590 nm) in the treatment of melasma compared with liposomal tranexamic acid.

METHODS AND ANALYSIS

This study is a controlled, randomised, double-blind, non-inferiority trial. This study will be performed in two centres (Universidade Nove de Julho Facility, Campus Vergueiro, and Galache Odontology Clinic, São Caetano do Sul, both in São Paulo State, Brazil). The sample (54 participants) will be divided into two groups in a 1:1 ratio; one group will receive active PBM and a placebo cosmetic and the other will receive sham PBM and liposomal tranexamic acid. Women presenting facial melasma, aged 35-50 years, with skin phototypes II-IV, will be eligible for inclusion. Women who use oral contraceptives, intrauterine devices, hormone replacement or photosensitive drugs, those with autoimmune disease and those who have undergone facial treatments in the last 3 months will be excluded from the study. The participants will receive PBM weekly for 12 weeks and will use the cosmetic two times per day at home during this period. The severity of melasma will be evaluated through the Melasma Area and Severity Index (MASI) as the primary outcome; pigmentation of the epidermis evaluated by corneomelametry, the photographic records, the global diagnosis of the face and the quality-of-life questionnaire (Brazilian Portuguese version of the Melasma Quality of Life Questionnaire) will assessed as secondary outcomes. All assessments will be made before starting the study (week 0), mid-study at 6 weeks and at the completion of treatment (week 12). MASI will also be evaluated during follow-up (weeks 16 and 20). The data will be analysed based on the intention-to-treat analysis using a generalised mixed model, and α <0.05 will be considered statistically significant.

ETHICS AND DISSEMINATION

The protocol was approved by the Research Ethics Committee of Universidade Nove de Julho (5 332 384). All participants will fill out the patient informed consent form. The results obtained in this trial will be presented at conferences and submitted for publication.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05326997).

Skin Pigmentation Types, Causes and Treatment-A Review

Human skin pigmentation and melanin synthesis are incredibly variable, and are impacted by genetics, UV exposure, and some drugs. Patients' physical appearance, psychological health, and social functioning are all impacted by a sizable number of skin conditions that cause pigmentary abnormalities. Hyperpigmentation, where pigment appears to overflow, and hypopigmentation, where pigment is reduced, are the two major classifications of skin pigmentation. Albinism, melasma, vitiligo, Addison's disease, and post-inflammatory hyperpigmentation, which can be brought on by eczema, acne vulgaris, and drug interactions, are the most common skin pigmentation disorders in clinical practice. Anti-inflammatory medications, antioxidants, and medications that inhibit tyrosinase, which prevents the production of melanin, are all possible treatments for pigmentation problems. Skin pigmentation can be treated orally and topically with medications, herbal remedies, and cosmetic products, but a doctor should always be consulted before beginning any new medicine or treatment plan. This review article explores the numerous types of pigmentation problems, their causes, and treatments, as well as the 25 plants, 4 marine species, and 17 topical and oral medications now on the market that have been clinically tested to treat skin diseases.

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.

Efficacy and safety of Politranexamide® liposomal emulsion on facial melasma: A comparative study

INTRODUCTION

Melasma is a human melanogenesis dysfunction that results in localized, chronic acquired hypermelanosis of the skin difficult to treat.

METHODS

This prospective, randomized, single-blind, study aimed to compare the efficacy and tolerability of a liposomal emulsion based on Politranexamide® (SAMPLE A) with that of a competitor based on acetylglucosamine, ethyl linoleate and phenyl ethyl resorcinol (SAMPLE B) in patients affected by facial melasma on 26 patients. Disease severity was assessed by the Melasma Area Severity Index (MASI) at baseline and after 6 and 12 weeks of therapy. All patients were subjected to photo documentation using DermaView camera and Antera 3D camera.

RESULTS

The mean MASI score at baseline was 10.93 ± 7 in the group A and 9.34 ± 6.29 in the group B, respectively. A significant decrease in MASI score from baseline was noted in both treatment groups as early as 6 weeks of follow-up (p = 0.00096 for SAMPLE A and p = 0.0049 for SAMPLE B) and was confirmed at the end of the treatment (p = 0.0006 for SAMPLE A and p = 0.00039 for SAMPLE B). Intergroup comparison revealed a greater improvement of melasma among patients in group A compared to those in group B that was quite statistically significant at weeks 6 (p = 0.055009) and significant after 12 weeks of follow-up (p = 0.032942). Both treatment groups experienced an improvement in Antera average level of melanin.

CONCLUSION

Our results suggested Politranexamide® to be a useful and safe therapeutic option in treating melasma, more effective than competitor used in this study.

Tranexamic acid in melasma: A focused review on drug administration routes

BACKGROUND

Melasma is a disorder of hyperpigmentation and vascularization often found in women between the ages of 20 and 40. The pathogenesis is unknown, but melasma often occurs in sun-exposed areas of the face, forearms, and back. Risk factors include family history, increased estrogen/progesterone, certain medications, and UV exposure. Melasma is typically treated with topical hydroquinone (HQ); however, it is often refractory to treatment. Tranexamic acid (TXA) is a plasmin inhibitor used off-label in the treatment of melasma. TXA can be administered orally, topically, or intralesionally.

AIMS

The purpose of this review is to characterize the wide variety of TXA delivery methods for melasma treatment and the efficacy of these methods compared with traditional treatments.

PATIENTS/METHODS

A comprehensive PubMed and Embase search was conducted in May 2022 using the phrases tranexamic acid and melasma. Forty-six articles were included in this review.

RESULTS

Oral, intralesional, and topical TXA is safe and effective treatments for melasma. They have been studied in a variety of randomized controlled trials and have been compared with several traditional treatments. Overall, MASI scores in patients using TXA in any form improved.

CONCLUSIONS

Oral TXA was found to be the most effective, especially in cases of refractory melasma; however, it caused GI upset and menstrual irregularities in many patients. The pro-thrombotic nature of this drug must be considered before safely prescribing to patients. Intralesional injections and microneedling with topical TXA were found to be effective alternatives to oral treatment. Lastly, topical TXA alone was found to be the least effective method but can be combined with other cosmeceuticals to improve outcomes. Topical TXA was also found to be better tolerated than hydroquinone, a traditional topical melasma treatment.

Efficacy and safety of topical agents in the treatment of melasma: What's evidence? A systematic review and meta-analysis

BACKGROUND

Various topical agents have been used to treat melasma; however, a large-scale evaluation among the currently available treatment is lacking.

OBJECTIVES

The aim of this study was to evaluate the efficacy and safety of topical agents for melasma.

METHODS

The MEDLINE, Embase, Web of Science, Cochrane, and Alt-Healthwatch databases were searched in November 2021. Original studies that reported pre- and post-treatment Melasma Area Severity Index (MASI)/modified Melasma Area Severity Index (mMASI) scores and/or adverse effects (AEs) were eligible for inclusion. The main outcome was the efficacy analyzed by the changes in the pre- and post-treatment with standardized mean difference (SMD) of MASI/mMASI scores; the AEs were calculated with incidence proportion by the reported percentage of skin irritations.

RESULTS

A total of 45 studies (2359 patients) and 55 studies (4539 patients) met the inclusion criteria for efficacy and AEs, respectively. Hydroquinone (HQ) monotherapy (SMD -1.3, 95% CI [-1.6 to -1.0]), HQ-containing combination therapy (-1.4, [-1.7 to -1.1]), cysteamine (-1.6, [-2.0 to -1.2]), tranexamic acid (-1.5, [-2.0 to -1.1]), azelaic acid (-1.3, [-1.7 to -1.0]), and kojic acid (-0.9, [-1.3 to -0.5]) demonstrated comparable efficacy, while zinc sulfate did not exhibit statistically significant improvement (-1.2, [-2.7 to 0.4]). HQ-containing combination therapy (50.9%) and cysteamine (42.2%) demonstrated the highest incidence of irritation, while azelaic acid (18.7%), kojic acid (5.3%), and tranexamic acid (0.8%) revealed a lower risk.

CONCLUSIONS

In this meta-analysis, non-HQ agents except zinc sulfate may be considered as an alternative to HQ-containing agents. However, treatment should be guided by patient's tolerance, availability, and physicians' experience.

Mechanism of Action of Topical Tranexamic Acid in the Treatment of Melasma and Sun-Induced Skin Hyperpigmentation

Tranexamic acid (TXA) has anti-plasmin activity and has been shown when administered orally to be effective against melasma, for which it is considered first-line pharmacotherapy. Several studies have shown that topically applied TXA is also effective against melasma and skin hyperpigmentation caused by sunburn and inflammation. The TXA concentration in the epidermis and dermis/vasculature has been estimated from its distribution in the skin after closed application, and topically applied TXA has thus been shown to act on neutrophils and mast cells in the dermis and on the vascular system. It is unlikely that topically applied TXA acts on dermal neutrophils or mast cells or on the vascular system to form thrombi. As discussed in the present review, studies on the effects of topical TXA on the hyperpigmentation process indicate that the resulting skin-lightening mechanism involves the suppression of cytokine/chemical mediator production, which stimulates melanin production via the keratinocyte-derived urokinase-type plasminogen activator and plasminogen derived from dermal vascular in the basal layer of the epidermis, thereby suppressing the production of excessive melanin to prevent hyperpigmentation.

Comparison of the Efficacy of Intralesional Tranexamic Acid Versus Topical 4% Hydroquinone in Treating Melasma

Objectives: To compare the efficacy of intralesional tranexamic acid and topical 4% hydroquinone in the treatment of melasma.

Study design: This comparative prospective study was conducted at the Dermatology Department, Pak Emirates Military Hospital Rawalpindi, Pakistan from October 16, 2018 to April 16, 2019.

Methodology: A total of 290 patients with melasma, 18 to 50 years of age, were included in this study. Patients with a history of discoid lupus erythematosus, pregnancy, lactation, anemia, and oral contraceptives or hormone replacement therapy were excluded from the study. Randomization was 1:1 for groups A and B, i.e., each upcoming patient was included in the next group. This randomization was supervised by another clinician. One hundred forty-five patients were placed in group A (intralesional tranexamic acid), while 145 were enrolled in group B (topical 4% hydroquinone). Follow-up was done at four weekly intervals for 12 weeks. After 12 weeks, the final response was assessed.

Results: In group A, the average age was 33.74 ± 6.67 years, while in group B it was 32.08 ± 6.08 years. Among the entire patients, the majority of the patients, 207 (71.38%), were in the age range of 18 to 35 years. Intralesional tranexamic acid was efficacious in 64 (44.14%) patients, while 47 (32.41%) of group B (topical 4% hydroquinone) showed complete improvement (p-value = 0.040).

Conclusion: This study concluded that using intralesional tranexamic acid is more effective in treating melasma than topical 4% hydroquinone.

A Dermoscopic Evaluation of Melasma Treated with Tranexamic Acid

Background: Melasma is a great challenge to the dermatologist. Choosing the proper treatment and the evaluation method are hard issues. Tranexamic acid [TA] injections showed promising results. The dermoscope is a non -invasive hand held tool Objective: To evaluate the efficacy of TA injections in the management of melasma and to assess a new dermoscopic score for assessment of melasma severity. Patients & Methods: Twenty-seven patients were enrolled in the study. They were assessed clinically, and by dermoscopy. An intradermal tranexamic acid was injected on the melasma. Melasma Area and Severity Index [MASI] was used to assess the melasma. Results: high significant difference was found between pre [4.700±2.1213] and post [2.811±2.0870] treatment values of MASI score [p= 0.0001]. Clinically TA treatment showed a dramatic improvement in MASI. Conclusion: The intradermal usage of TA can actually decrease improved the melasma. This was confirmed by the MASI scores and the dermoscope. The dermoscope could be considered as a useful objective score for melasma.

Efficacy and safety of 755-nm picosecond alexandrite laser with topical tranexamic acid versus laser monotherapy for melasma and facial rejuvenation: a multicenter, randomized, double-blinded, split-face study in Chinese patients

To compare the efficacy and safety of 755-nm picosecond alexandrite laser and topical tranexamic acid (TTA) combination therapy with laser monotherapy, for the treatment of melasma and facial rejuvenation. This multicenter, randomized, double-blinded, split-face study enrolled 37 patients who presented with melasma and photoaging. Facial halves were randomized to receive either laser and TTA combination therapy or laser monotherapy. Three treatments were delivered at 4-5 weeks intervals. Patients were followed up for 1, 3, and 6 months post-final treatment and evaluated by blinded investigators for hemi-Melasma Area and Severity Index (hemi-MASI), facial dyschromia, skin texture, laxity, and rhytids. Daily diaries rating healing progress for 7 days posttreatment and satisfaction grading were performed by all patients. Adverse events were recorded. Thirty-six patients completed the follow-up. Compared with the baseline, hemi-MASI, dyschromia, and skin texture on both halves improved significantly through the follow-up (p = 0.000). A significant difference in hemi-MASI and dyschromia between combination therapy halves and monotherapy halves was noticed at 1- and 3-month follow-ups (p < 0.05). The laser monotherapy halves displayed significantly less redness and sensitivity during the 7-day posttreatment recovery period (p < 0.05). Patients' satisfaction ratings for the combination therapy halves were higher than the monotherapy halves at 1-month follow-up (p < 0.05). No severe adverse events were observed. The picosecond alexandrite laser and TTA combination therapy demonstrated synergistic efficacy for hemi-MASI and dyschromia improvements over laser monotherapy. The optimization of the picosecond laser and TTA combination regimen needs further investigation.

The uses of tranexamic acid in dermatology: a review

Tranexamic acid is a plasmin inhibitor that is used off-label for the treatment of melasma. The use of tranexamic acid has expanded in the field of dermatology based on its anti-inflammatory and anti-melanin-producing properties, which include the treatment of rosacea, urticaria, and post-inflammatory hyperpigmentation. Tranexamic acid may have more uses in dermatology that require future studies. It should be used with caution during the COVID-19 pandemic given its procoagulant nature.

Tranexamic acid inhibits melanogenesis partially via stimulation of TGF-β1 expression in human epidermal keratinocytes

Oral tranexamic acid (TA) has been an effective treatment for melasma with unclear mechanism. The present study aimed to demonstrate the effect of TA on melanogenesis via regulation of TGF-β1 expression in keratinocytes. We firstly determined the expression level of TGF-β1 in TA-treated keratinocyte-conditioned medium (KCM). Then, the mRNA and protein levels of microphthalmia-associated transcription factor (MITF), tyrosinase (TYR) and tyrosinase-related protein 1 (TRP-1) of human epidermal melanocytes (NHEMs) in the presence of TA-treated KCM were evaluated via RT-PCR and western blot analysis. Moreover, melanin content and tyrosinase activity were quantified. TGF-β1 gene was knocked down by small interfering RNA (siRNA) in keratinocytes. The mRNA and protein levels of TGF-β1 in keratinocytes were significantly increased after TA treatment. Melanin contents, tyrosinase activity, protein and mRNA levels of TYR, MITF and TRP-1 were downregulated in NHEMs in the presence of TA-treated KCM. Knockdown of TGF-β1 in keratinocytes could attenuate the inhibitory effect of TA-treated KCM on melanogenesis. TA could stimulate TGF-β1 expression in keratinocytes, which further inhibits melanogenesis through the paracrine signalling.

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.

Targeting delivery and minimizing epidermal diffusion of tranexamic acid by hyaluronic acid-coated liposome nanogels for topical hyperpigmentation treatment

Hyperpigmentation is a common complaint and distressing problem in dermatology, and tranexamic acid (TA) is an effective treatment agent but limited by the delivery to melanocytes in the epidermis. Herein, a novel TA naogels (named HA/TA-LP), combining the advantages of liposomes and hyaluronic acid (HA), are prepared and assessed for topical hyperpigmentation treatment with targeting delivery and minimizing epidermal diffusion. Morphological characteristics indicate numerous TA-loaded liposomes packed in HA gels. In vitro cell studies using human A375 melanoma cells show that HA/TA-LP can promote the uptake of TA by targeting delivery with resulting inhibition of tyrosinase activity and melanin production. Guinea pigs are used to construct hyperpigmentation models and investigate the topical delivery and treatment efficacy of HA/TA-LP. In vivo topical delivery studies indicate HA/TA-LP realize the effective delivery into melanocytes with an ideal balance of effective permeability and minimizing epidermal diffusion. Subsequently, hyperpigmentation treatment assessments reveal that HA/TA-LP inhibit tyrosinase activity and melanin production under the radiation of UVB. Our study identifies favorable properties of HA/TA-LP for treating hyperpigmentation, and provides an experimental basis for further clinical application.

The Application of Skin Care Product in Melasma Treatment

Melasma is an acquired and chronic hyperpigmentation disorder which is recognized as one of the most psychologically distressing and difficult to cure forms of skin hyperpigmentation. It is associated with substantial quality of life impairments. Treatments of melasma include local application, oral medication, physical laser therapy and program combination therapy. However, routine treatment usually leads to the damage of skin barrier function, resulting in adverse reactions such as erythema, pruritus, post-inflammatory pigmentation and even scar. Skin care products contain a variety of active ingredients, which are widely concerned by cosmetic dermatologists because of high safety, good tolerance and the effect of improving the damaged skin barrier. Using skin care products alone or in combination with routine treatment not only can improve the curative effect for melasma, reduce side effects and recurrence rate, but also improve patient satisfaction. This article mainly describes the application of skin care products in the treatment of melasma.

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.

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.

Efficacy and safety of tranexamic acid in the treatment of adult melasma: An updated meta-analysis of randomized controlled trials

WHAT IS KNOWN AND OBJECTIVE

Tranexamic acid (TXA) is a novel treatment option for melasma; however, no consensus exists on its use. This study evaluates the efficacy and safety of TXA for melasma.

METHODS

A comprehensive literature review was conducted to search for randomized controlled trials comparing TXA alone, TXA as adjuvant to routine treatment and placebo. Changes in the Melasma Area Severity Index (MASI)/modified MASI (mMASI) between pre- and post-treatment and between a certain melasma treatment and TXA were the primary outcomes. Twenty-four trials comparing oral, topical or intradermal TXA with routine treatment were included in the meta-analysis.

RESULTS AND DISCUSSION

The change in MASI/mMASI scores at 4 (MD, 3.58; 95% confidence interval (CI), 2.15-5.01), 8 (MD, 5.08; 95% CI, 3.34-6.81), 12 (MD, 4.89; 95% CI, 3.80-5.97) and 16 (MD, 6.55; 95% CI, 2.62-10.48) weeks after treatment was all less than the baseline scores, regardless of the delivery route. The reduction in the MASI/mMASI scores between TXA adjuvant and routine treatment at 4 (MD, -0.43; 95% CI, -0.79 to -0.08), 8 (MD, -0.81; 95% CI, -1.09 to -0.54), 12 (MD, -1.10; 95% CI, -1.78 to -0.43) and 16 (MD, -1.12; 95% CI, -1.51 to -0.74) weeks was significant. However, the superiority of TXA was not detected when the topical or intradermal route was adopted. No serious adverse events occurred with the use of TXA.

WHAT IS NEW AND CONCLUSION

These results suggest that oral TXA is an available, effective and safe alternative treatment for melasma.

Efficacy of topical versus intradermal injection of Tranexamic Acid In Egyptian melasma Patients: A randomised clinical trial

BACKGROUND

Melasma is one of the common pigmentary problems affecting females in our community, owing to the frequent use of hormonal contraceptives as well as our sunny climate. A lot of treatment options are available but none of them is completely satisfactory. Many patients prefer the use of topical preparations and minimally invasive methods. Tranexamic acid (TA) is a potential treatment option for hyperpigmentation with different delivery routes.

AIM

We designed the study in order to evaluate the efficacy of TA in melasma using 2 different routes of delivery.

PATIENTS AND METHODS

A randomised clinical trial was performed on 60 female patients with melasma, they randomly divided into three groups; A, B and C. Group (A) patients received TA (4 mg/mL) intradermal injections every 2 weeks with, group B received TA (10 mg/mL) intradermal injections every 2 weeks, group C received TA cream (10% concentration) twice daily, treatment continued for 12 weeks in all groups. Melasma Area and Severity Index (MASI) scores were measured for each patient before and after completion of treatment.

RESULTS

The percentage of MASI score reduction was highest in group B (62.7%) versus (39.1%) in group A, while the percentage of MASI reduction was the lowest in group C (4.2%).

CONCLUSION

Tranexamic acid is a safe effective and well-tolerated treatment option for melasma patients. Intradermal injection of TA leads to better results than the topical application. Topical TA cream (even in a high concentration) produce fair improvement of melasma.

The efficacy of oral vs different dilutions of intradermal tranexamic acid microinjections in melasma-A randomized clinical trial

Melasma is a common acquired disorder of pigmentation, remains challenging despite numerous treatment modalities. Tranexamic acid (TXA) has emerged as a potential treatment for melasma. Different forms of TXA (oral, topical, and intradermal microinjections) have shown promising results. To evaluate and compare the efficacy of oral vs different dilutions of intradermal TXA in melasma. A total of 45 female patients with melasma were randomly and equally assigned to three treatment groups. Group A (oral TXA 250 mg bid), Group B (100 mg/mL intradermal TXA) & Group C (4 mg/mL intradermal TXA) every 2 weeks, treatment period was 8 weeks. At 8 weeks, a significant reduction in the mMASIwas noted in groups A, B, and C (P value .002, .003, and .005). Melanin index (MI) was significantly reduced in groups A, B, and C (P value .016, .005, and .003). Erythema index (EI) showed significant improvement in group A (P value .028), however was statistically insignificant for groups B and C. No statistically significant difference was found between the three groups as regards changes in mMASI, MI, and EI at 8 weeks. Both oral and intradermal microinjections of TXA regardless dilution appear to be effective and safe in treatment of melasma with comparable results.

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.

The efficacy and safety of topical tranexamic acid (liposomal or lotion with microneedling) versus conventional hydroquinone in the treatment of melasma

BACKGROUND

Robust evidence regarding the efficacy of topical tranexamic acid (TA) on melasma in Chinese population is lacking.

OBJECTIVE

To evaluate the efficacy and safety of 1.8% liposomal TA and microneedling with 5% TA solution on melasma.

METHODS

Sixty melasma patients were enrolled and randomized to receive 1.8% liposomal TA twice daily, microneedling with 5% TA solution weekly or 2% hydroquinone every night. Objective and subjective assessments were obtained at baseline, 4, 8, and 12 weeks.

RESULTS

27.8% of patients of liposomal TA group, 33.3% of microneedling with TA solution group, and 30.0% of hydroquinone group were recognized as "more than 50% improvement." At the endpoint, the melanin index (MI) in all treatment groups was significantly decreased, while the improvement of MI in microneedling with TA solution group and hydroquinone group is higher than liposomal TA group. The erythema index (EI) was significantly diminished in liposomal TA group and microneedling with TA solution group. Dermatoscopy and reflectance confocal microscopy revealed decreased brown granules in all groups and reduced telangiectasia in liposomal TA group and microneedling with TA solution group.

CONCLUSION

1.8% liposomal TA and microneedling with 5% TA solution are both effective and safe on melasma.

Clinical evaluation of efficacy and tolerability of cysteamine 5% cream in comparison with tranexamic acid mesotherapy in subjects with melasma: a single-blind, randomized clinical trial study

This study was aimed at evaluating the efficacy of Tranexamic Acid (TA) mesotherapy versus cysteamine 5% cream in the treatment of melasma. This single-blind, randomized clinical trial was conducted among 54 subjects between 2018 and 2019. Cysteamine 5% cream group was instructed to apply the cream on the melasma lesions 30 min before bed for 4 consecutive months. Conversely, 0.05 mL (4 mg/mL) TA mesotherapy was performed by a physician every 4 weeks until 2 months. The severity of melasma was evaluated using both Dermacatch® device and the modified Melasma Area Severity Index (mMASI). The most remarkable improvement rate was observed in the TA group at the third visit based on mMASI and Dermacatch® values at 47% and 15% in turn. The mMASI scores were substantially improved in both groups at the second visit (cysteamine vs TA 8.48 ± 2.34 and 7.03 ± 3.19; P = 0.359) and third visit (cysteamine vs TA 6.32 ± 2.11 and 5.52 ± 2.55; P = 0.952) as compared to baseline (cysteamine vs TA: 11.68 ± 2.70 and 10.43 ± 2.69). Dermacatch® values were significantly declined at the second and third visits (cysteamine vs TA 42.54 ± 12.84 and 38.75 ± 9.80, P = 0.365; 40.74 ± 12.61 and 36.17 ± 10.3, P = 0.123, respectively) compared with baseline (cysteamine vs TA 45.76 ± 13.41 and 42.41 ± 10.48), although the improvement rates between two groups were not significantly different. Findings suggest that none of the cysteamine and TA mesotherapy treatments measured by both mMASI and Dermacatch® methods have substantial advantages over the other; however, complications are less in the cysteamine than the TA mesotherapy group.

"The unfair drive to be fair": Psychosocial aspects and implications of the use of skin lightening agents

The quest to be fair is not a concept of the new world. For centuries untold, having a lighter skin tone has been considered as a trait of beauty and supremacy. Society implicates fairness as a factor for getting a prospective life partner. Media portrays fair skin tone as a predecessor for success. These subtle influences affect young minds and drive them towards wanting fair skin. Physicians observe that it is one of the most common forms of body dysmorphic disorder. This article aims to highlight the psychosocial factors that mold this mentality and the possible ill effects it can have on a person, both psychologically as well as physically.

New topical tranexamic acid derivative for the improvement of hyperpigmentation and inflammation in the sun-damaged skin

BACKGROUND

Skin-lightening products are used worldwide to treat persistent pigmentation disorders that impact our quality of life and self-confidence. However, consumers of cosmetic and over-the-counter skin lighteners struggle to find products that perform to their expectations. New, safe, and effective bioactives are needed to fill this gap.

OBJECTIVE

To investigate the safety and skin-lightening performance of a new topical tranexamic acid derivative, that is, cetyl tranexamate mesylate.

METHODS

The test material was a facial serum containing 2.0% (w/w) of the new bioactive. Safety was evaluated by a modified Human Repeat Insult Patch Test with 54 subjects of either sex. Performance was objectively assessed based on the improvement of melanin and erythema indexes through time, and also subjectively by photographs and self-perception questionnaires. Thirty-five female subjects applied the serum twice a day for 8 weeks.

RESULTS

No questionable adverse reactions were observed. Melanin and erythema indexes improved significantly and continuously from the baseline to the end of the study (-16.9% and -34.3%, respectively). Photographs further support instrumental data. On average, after 2 weeks, the subjects already noticed an improvement in skin tone (79.3%), a reduction in dark spots (78.6%), and an improvement in facial redness (77.1%).

CONCLUSION

A topical serum containing cetyl tranexamate mesylate was well-tolerated and successfully improved the overall facial skin tone, as well as the appearance of dark spots and redness.

Micro-needling versus fractional carbon dioxide laser for delivery of tranexamic acid in the treatment of melasma: A split-face study

BACKGROUND

Tranexamic acid (TXA) in oral, topical, and intra-dermal injection routes showed efficacy in melasma treatment. Micro-needling and fractional carbon dioxide (CO₂ ) laser were reported to enhance the drug delivery of TXA.

AIMS

This study aimed at comparing the use of micro-needling and fractional CO₂ laser for drug delivery of TXA in the treatment of facial melasma.

PATIENTS/METHODS

Thirty female patients with bilateral symmetrical facial melasma were subjected to micro-needling, for one side of the face, and fractional CO₂ laser, for the other, followed by an immediate topical application of TXA solution 4 mg/mL. Patients received six biweekly sessions.

RESULTS

Two weeks after the last session, a significant reduction in baseline modified melasma area and severity index (mMASI) score was observed on both sides. The mean ± SD baseline mMASI dropped from 3.43 ± 1.84 to 1.59 ± 1.51 (mean reduction 57.73%, P < .001) and from 3.51 ± 1.84 to 1.78 ± 1.51 (mean reduction 55.82%, P < .001) in the micro-needling-treated side and in the fractional CO₂ laser-treated side, respectively. However, no statistically significant differences were found between the two sides (P = .81).

CONCLUSIONS

Micro-needling and fractional CO₂ laser are equally safe and effective for the delivery of TXA in the treatment of facial melasma.

Comparison of efficacy of Tranexamic Acid Mesotherapy versus 0.9% normal Saline for Melasma; A split face study in a Tertiary Care Hospital of Karachi

Objectives:

To compare the efficacy of tranexamic acid mesotherapy versus 0.9% normal saline for melasma by split-face study.

Methods:

It was a non-randomized clinical trial performed at the Dermatology ward of JPMC from September 2018 to June 2019 after getting approval from the Ethical Committee. A total of sixty patients were recruited in the study, who had symmetrical melasma on their faces. Both halves of the face were treated by Injection Tranexamic Acid (TA) with a dose of 4mg/ml and Normal Saline (NS) two weekly for twelve weeks. Hemi Modified Melasma Area and Severity Scoring (H-mMASI) was calculated at the start and end of the study. Analyses were done by SPSS version 23. P < 0.05 was taken as significant.

Results:

Mean of H-mMASI score was compared on both sides at the end of study, which showed significant reduction in mean score from 3.19 ±2.57 to 1.52 ± 1.2 (P < 0.05) on A side as compared to decline in scores on NS side from 3.46 ± 2.7 to 3.45 ± 2.6 (P > 0.05). Erythema, swelling, and burning were documented as temporary side effects on both sides.

Conclusion:

Tranexamic Acid (TA) mesotherapy can be considered as the most cost-effective, safe and directly observed therapy for melasma which showed significant improvement when old prior therapies have failed.

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.

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.

Tranexamic Acid Inhibits Angiogenesis and Melanogenesis in Vitro by Targeting VEGF Receptors

Melasma is a common but complex skin condition concerning cosmetic problems. Tranexamic acid (TA) has been proved to be effective in treatment of melasma with still unclear mechanisms. Here, we show that VEGF165 enhanced the expression of VEGF receptors (VEGFRs, including VEGFR-1, VEGFR-2 and NRP-1) in human umbilical vein endothelial cells (HUVECs), which was attenuated by TA. VEGF165 also promoted tyrosine phosphorylation of VEGFR-1 and VEGFR-2 in HUVECs, which was again abolished by TA. TA further showed similar effects to neutralization of VEGFR-1 and VEGFR-2 in inhibiting cell proliferation, migration, invasion and tube formation of HUVECs induced by VEGF165, suggesting that TA could inhibit angiogenesis by targeting VEGFRs in HUVECs. In addition, VEGF165 enhanced the expression of VEGFRs and promoted tyrosine phosphorylation of VEGFR-1 and VEGFR-2 in normal human melanocytes, which were also attenuated by TA. Furthermore, TA showed similar effects to neutralization of VEGFR-1 and VEGFR-2 in inhibiting tyrosinase activity, melanin production and even melanogenic proteins induced by VEGF165, suggesting that TA could reduce melanogenesis via inhibiting activation of VEGFRs and subsequent expression of melanogenic proteins in melanocytes. Taken together, we demonstrate that TA can inhibit angiogenesis and melanogenesis in vitro at least in part by targeting VEGFRs, which may offer a new understanding of the pathogenesis of melasma as well as the molecular mechanism for TA in treatment of the disease.

Activation of VEGF receptors in response to UVB promotes cell proliferation and melanogenesis of normal human melanocytes

VEGF receptors (VEGFRs) are high-affinity receptors for VEGF and signaling via VEGFRs extends beyond the classical roles in blood vessel formation. We previously showed VEGFRs were also expressed in epidermal keratinocytes and activation of VEGFR-2 by ultraviolet B (UVB) was involved in the pro-survival mechanism. Here, we show that both VEGF165 and UVB enhanced the expression of VEGFRs (including VEGFR-1, VEGFR-2 and NRP-1) in normal human melanocytes, and increased expression of VEGFRs by UVB was mediated through hypoxia and oxidative stress. Also, VEGF165 and UVB promoted tyrosine phosphorylation of VEGFR-1 and VEGFR-2, and UVB-induced phosphorylation of VEGFR-1 and VEGFR-2 required PKA but not P38 MAPK. In addition, UVB and VEGF165 contributed to the over-expression of melanogenic proteins in melanocytes, which could be reduced by neutralization of VEGFR-1 and/or VEGFR-2. UVB, but not VEGF165 promoted cell proliferation, while neutralization of VEGFR-1 and/or VEGFR-2 abolished this effect. UVB showed stronger than VEGF165 in promoting tyrosinase activity and melanin production, while neutralization of VEGFR-2 was stronger in reducing these effects than that of VEGFR-1. Furthermore, tranexamic acid (TA) decreased tyrosinase activity and melanin production via inhibiting activation of VEGFRs and subsequent expression of melanogenic proteins in melanocytes. Taken together, we demonstrate that VEGFRs are functionally involved in UVB-induced melanogenesis, and TA can inhibit melanogenesis at least in part by targeting VEGFRs in melanocytes.

The emerging importance of tranexamic acid in dermatology

Tranexamic acid (TA) is an antifibrinolytic agent, increasingly recognized as being of utility for a wide variety of skin diseases. We review the evidence supporting the use of TA for a range of dermatological indications, including (among others) melasma, postinflammatory hyperpigmentation, urticaria, angio-oedema and haemostasis, in addition to practical considerations of its use by dermatologists.

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.

Melasma: Updates and perspectives

Management of melasma is highly challenging due to inconsistent treatment results and frequent relapses. However, recent studies revealed that melasma may not only be a disease of melanocytes, but also a photoaging skin disorder. Herein, we attempt to validate that melasma is indeed a photoaging disorder by presenting the histopathologic findings of melasma: solar elastosis, altered basement membrane, increased vascularization and increased mast cell count. We also provide some therapeutic implications based on these findings and a discussion on the latest updates and perspectives regarding treatment.