Effect of melasma on quality of life in a sample of women living in southern Brazil

Understanding the perception of sunscreen utility in African Americans

Dyschromia is a top diagnosis among African Americans (AA). Sunscreen is an essential part of its management, but AA have low sunscreen use. We sought to examine the perception of sunscreen utility in dyschromia and photoaging among patients who identify as AA or Black. This cross-sectional study recruited participants from the Case Western Reserve University Academic Dental Clinic. Participants completed an electronic survey that contained questions related to sunscreen use, knowledge of the sun's role in hyperpigmentation and photoaging, and whether sunscreen could be used for hyperpigmentation and photoaging. Of the 151 participants recruited, 63.6% (n = 96) were women and 36.4% (n = 57) were men. Consistent with previous reports, participants had lower sunscreen use (20.5%) than whites (43.5%). The majority of participants (80.1% and 58.3%, respectively) didn't attribute the sun to hyperpigmentation or photoaging. Participants with dark/brown spots were significantly more likely to not attribute the sun to hyperpigmentation than those without spots. (p = 0.003) Limitations for this study include its small sample size, recall and reporter bias, question misinterpretation, and lack of question neutrality. This study highlights the knowledge gap of a major contributing factor to dyschromia which in turn could be leading to their view of the decreased utility of sunscreen.

Efficacy and safety of mesotherapy with tranexamic acid versus vitamin C in the treatment of melasma: A meta-analysis and systemic review

BACKGROUND

The exact pathogenesis of melasma is not yet known, and its treatment remains challenging. Mesotherapy with tranexamic acid (TXA) and vitamin C was both reported to have certain effects on melasma. In spite of that several articles have compared the efficacy and safety of the two drugs on melasma, most of them were clinical study with small sample size.

AIMS

To evaluate the efficacy and safety of mesotherapy with TXA versus vitamin C in treating melasma through meta-analysis and systemic review.

METHODS

The authors searched PubMed, Web of Science, Springer, and ScienceDirect for studies that compared mesotherapy with TXA versus vitamin C as a treatment for melasma. Primary outcomes were change in melasma area and severity index (MASI) before and after the treatment.

RESULTS

Finally, five studies with a total of 127 patients were included in the systematic review. There was no statistic difference in the change in MASI score between the TXA and vitamin C groups (mean difference, 0.16; 95% CI, -0.79 to 1.11).

CONCLUSIONS

Mesotherapy with both TXA and vitamin C is safe and effective in the treatment of melasma.

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 Effect of Melasma on the Quality of Life in People with Darker Skin Types Living in Durban, South Africa

Melasma is a common skin disorder of acquired hyperpigmentation that appears commonly on the face. Although asymptomatic, melasma causes psychosocial and emotional distress. This study aimed to assess melasma's severity on people with darker skin types, evaluate the effects of melasma on the quality of life (QoL), and establish QoL predictors in affected individuals. This was a cross-sectional analytic study that enrolled 150 patients from three private dermatology clinics in Durban, South Africa who were diagnosed with melasma. The severity of melasma alongside QoL were measured using a melasma area and severity index (MASI) score and melasma quality of life scale (MELASQoL), respectively. The associations among factors and QoL were explored using multivariable methods and stepwise regression analysis. p-values less than 0.05 were considered significant. Enrolled patients were predominantly females (95%), of which 76% were of black African ethnicity, 9% were of Indian ethnicity, and 15% had mixed ancestry, with an average age of 47.30 years. Family history revealed that 61% had no prior melasma cases, while 39% had affected relatives, most commonly mothers (41%). The cheeks were the most common site for melasma. MASI score of Masi (β = 0.209, t = 2.628, p < 0.001), the involvement of cheeks (β = -0.268, t = -3.405, p < 0.001), level of education (β = -0.159, t = -2.029, p = 0.044), and being menopausal (β = -0.161, t = -2.027, p = 0.045) were found to be predictors of QoL. A regression model was created to forecast MELASQoL using these four predictors. This equation's significance lies in its ability to enable the remote assessment of MELASQoL based on these four variables. It offers a valuable tool for researchers and medical professionals to quantitatively and objectively evaluate the impact of melasma on an individual's quality of life.

Efficacy and safety of laser-related therapy for melasma: A systematic review and network meta-analysis

BACKGROUND

Melasma is a prevalent, persistent hyperpigmentation disorder that negatively affects the psychological health of patients. However, the treatment outcome remains unsatisfactory due to the complexity of pathogenesis, recurrence characteristics, and relatively high morbidity.

OBJECTIVES

To compare the performance of laser-related therapies in improving the melasma area severity index (MASI) score of melasma and the occurrence of adverse effects by network meta-analysis (NMA).

METHODS

From the inception to November 2022, eligible randomized controlled trials were identified. Two investigators independently searched relevant studies from PUBMED, EMBASE, and the Cochrane Library database.

RESULTS

A total of 39 clinical studies with 1394 participants were eligible for enrollment. For efficacy, the NMA demonstrated that Q-switched Nd: YAG laser + topical medications (QSND+TM) was superior to Q-switched Nd:YAG laser (QSND) [MD = -4.21 (-6.80, -1.63)], Er: YAG laser + topical medications (ERYL+TM) [MD = -3.52 (-6.84, -0.19)], and picosecond laser + topical medications (PICO+TM) [MD = -4.80 (-9.33, -0.27)]. The microneedling + topical medications (MN+TM) was superior to picosecond laser (PICO) [MD = -5.26 (-10.44, -0.08)] and topical medications (TM) [MD = -5.22 (-9.20, -1.23)]. The top five of the surface under the cumulative ranking curve value (SUCRA) are Q-switched Nd:YAG laser + topical medications (QSND+TM 85.9%), oral tranexamic acid (oTA 80.1%), microneedling + topical medications (MN+TM 79.7%), Q-switched Nd:YAG laser + intense pulse light (QSND+IPL 78.9%), and fractional carbon dioxide laser + topical medications (FCDL+TM 70.5%).

CONCLUSIONS

In conclusion, the Qs-Nd:YAG laser with topical medications is the first choice for treating melasma according to the SUCRA value. Among the three treatment modalities, namely MN + TM, PICO, and TM, our recommendation favors MN+TM as the superior choice for enhancing the curative efficacy in melasma. However, the actual clinical choice should also take into account the adverse effects, the skin type of the patient, the duration of the disease, and other relevant factors.

Efficacy and Safety of Topical Tranexamic Acid Alone or in Combination with Either Fractional Carbon Dioxide Laser or Microneedling for the Treatment of Melasma

INTRODUCTION

Tranexamic acid (TXA) is a promising treatment modality for melasma. Microneedling (MN) and fractional carbon dioxide (CO2) laser were reported to enhance TXA transepidermal delivery.

OBJECTIVES

To compare efficacy and safety of topical TXA alone or in combination with either fractional CO2 laser or MN for treatment of melasma.

METHODS

Thirty females with facial melasma were divided randomly into 3 equal groups after excluding pregnant and lactating women and those using oral contraceptives or other hormonal therapy. Patients of group A were treated with fractional CO2 laser and those of group B were treated with MN (4 sessions, 3 weeks apart for both) with immediate topical application of TXA 5% solution after sessions and daily application of 5% TXA cream for both groups. Patients of group C were treated by topical daily application of TXA 5% cream. Evaluation was done by modified melasma area and severity index scores (mMASI), patient satisfaction and dermoscopy.

RESULTS

Statistically significant improvement of mMASI was reported in all studied groups with a significantly better improvement in patients of groups A and B than those of group C, meanwhile the difference between groups A and B was statistically insignificant.

CONCLUSIONS

Topical TXA is a safe and fairly effective treatment modality for facial melasma. Combining TXA with either fractional CO2 laser or MN yielded significantly better improvement than when used alone. Fractional CO2 laser carries the risk of post-inflammatory hyperpigmentation in patients with skin types III and IV and requires meticulous patient selection.

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.

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.

The effect of patient characteristics on illness perception and sun protection behaviors in melasma

BACKGROUND/AIM

Melasma, a significant cosmetic problem, has been accepted by some authors as a photoaging illness in recent times. There is no published study evaluating the effects of the clinical and sociodemographic findings on illness perception and sun protection behaviors (SPBs) in patients with melasma.

PATIENTS/METHODS

Sociodemographic data, personal characteristics, and clinical features of 150 patients with melasma were recorded in this cross-sectional study. They were analyzed for their SPBs in three groups as "never," "rarely/sometimes," and "often/always." Patients completed the Melasma Quality of Life (QoL) Scale and Revised-Illness Perception Questionnaire.

RESULTS

Melasma patients with higher clinical severity and Qol scores, lower education level, concomitant chronic illness, and a history of previous melasma treatment thought more frequently that melasma had negative serious consequences. Majority of the patients blamed sun exposure as the cause of the melasma. However, SPBs were more frequent only in patients with higher socioeconomic and educational levels, a previous history of melasma treatment, and evaluating their disease as a chronic condition. Neither Qol nor clinical severity score had a significant effect on sun exposure causal attribution or SPBs. No significant effect of patients' perception of melasma was determined on the use of sunscreen or protective hat.

CONCLUSION

Being aware of the factors affecting the perception of melasma and QoL of patients might be helpful in making persistent individual recommendations for the regulation of SPBs.

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.

Mechanisms of ultraviolet-induced melasma formation: A review

Melasma, a pigmentation disorder, commonly occurs in exposed skin areas and can be attributed to several factors. Ultraviolet radiation (UVR) is the primary factor that induces and aggravates melasma. Considering gene expression, exposed skin areas experience abnormal gene expression, involving melanin metabolism, oxidative stress, impaired skin barrier function, and abnormal composition of nerve factors. From a histological perspective, UVR can cause basement membrane collapse, melanocyte sinking, and disorders of skin lipid metabolism. Emerging therapies have focused on these pathological alterations in melasma, including platelet-rich plasma, mesotherapy, and phytochemicals. Understanding the role of UVR in the development of melasma can facilitate early prevention and highlight the future direction of melasma treatment.

Photoprotection for Skin of Color

Photoprotection behaviors can mitigate skin damage caused by ultraviolet radiation, and common methods include seeking shade, avoiding sun exposure during peak daylight hours, wearing sun-protective clothing, applying sunscreen, and using sunglasses. While the role of sun protection in preventing sunburns, photoaging, and skin cancer is well established in fair-skinned populations, individuals with skin of color (SOC) are presumed to suffer fewer negative effects from solar radiation. Thus, the importance of photoprotection in this population is understudied and may be underestimated. In SOC populations, sun exposure is known to cause pigmentary disorders, photoaging, and basal cell carcinoma (BCC), highlighting the potential benefits of photoprotection. Although SOC populations tend to practice photoprotection by seeking shade and wearing sun-protective clothing, survey and interview-based studies have consistently found relatively low use of sunscreen among these populations. Common motivators for photoprotection in individuals with SOC include preventing sunburn and pigmentation, with the prevention of skin cancer being a less important reason. As a skin cancer risk behavior, indoor tanning is relatively rare in SOC populations, but its use may increase with acculturation to US norms. While more studies are necessary to clarify whether photoprotection behaviors may decrease skin cancer-related mortality in SOC populations, regular dermatologic care and counseling on photoprotection remain essential in patients with SOC for overall skin health.

Evaluating the quality of life among melasma patients using the MELASQoL scale: A systematic review and meta-analysis

Background

According to the literature, pigmentary disorders have a significantly negative impact on a person’s health-related quality of life. Moreover, among pigmentary disorders, incidence of melasma ranks high. The Melasma Area and Severity Index (MASI) is the scale that is generally used to evaluate a melasma-affected area and its severity. However, the relationship between the MASI and Melasma Quality of Life (MELASQoL) scores, as well as the impact of melasma on patients’ quality of life, remain unclear.

Objectives

To explore the influence of melasma on patients’ lives, analyze the relationship between the MASI and MELASQoL scores, and identify the factors that may be influencing the quality of life of patients with melasma.

Methods

Two reviewers independently searched four databases (PubMed, Embase, the Cochrane Library, and Web of Science) for literature on quality of life of patients with melasma. In addition to an epidemiological study, a cross-sectional study, and validation studies, gray literature was also included. StataSE version 16 software was used for the meta-analysis. The score of each item on the MELASQoL scale was determined using a random-effects model.

Results

Fourteen studies with a total of 1398 melasma patients were included in the systematic review, four of which were eligible for meta-analysis. The relationship between the MELASQoL and MASI scores was found to be mixed. Five studies concluded that the MASI and MELASQoL scores were statistically correlated, while seven studies found no statistical correlation between the two. It is obvious that melasma causes emotional distress and has a negative impact on patients’ social lives. Patients were most bothered by the appearance of their skin condition. However, the MELASQoL score had no definite correlation with patient characteristics such as age, education levels, and history.

Conclusion

Melasma has a significant negative impact on patients’ quality of life. Thus, evaluating the quality of life of patients with melasma should not be ignored. Additionally, utilization of the MELASQoL scale should be considered in the care plan. Further studies with larger sample sizes are needed to confirm the relationship between melasma and quality of life.

Combined isobutylamido thiazolyl resorcinol and low-fluence Q-switched Nd: YAG laser for the treatment of facial hyperpigmentation: A randomized, split-face study

BACKGROUND

Isobutylamido thiazolyl resorcinol (ITR) is a novel anti-tyrosinase recently shown to be effective in the treatment of hyperpigmentation. Low-fluence Q-switched Nd:YAG 1064-nm laser (LFQS) has proven to be effective for various hyperpigmentary conditions. However, there is no study on the efficacy and safety of combined ITR and LFQS treatment.

OBJECTIVES

To compare the efficacy and safety of combined ITR and LFQS with LFQS monotherapy for facial hyperpigmentation.

MATERIALS AND METHODS

Patients with symmetrical facial hyperpigmentation were treated with five sessions of once weekly LFQS on the whole face. One side was randomly treated with ITR and the other side received a placebo cream for 12 weeks. Patients were followed for 8 weeks after the last laser treatment. Relative lightness index (RL*I), Facial Hyperpigmentation Severity Score on the malar area (FHSS_m ), patient satisfaction, recurrence, and adverse events were recorded.

RESULTS

Twenty-four patients completed the study. Both sides demonstrated significant reductions of mean RL*I and mean FHSS_m from baseline (P < .01). At the 4th week, the ITR-treated side showed more improvement of mean RL*I than the placebo-treated side (62.5% vs 47.3% improvement, P < .05). The mean FHSS_m on the ITR-treated was reduced at a significantly higher percentage than the placebo-treated side (54.4% vs 40.2% reduction, P < .05). Partial recurrence was observed on both sides. No serious side effects were noted.

CONCLUSION

Combined ITR and LFQS therapy was more superior than LFQS monotherapy in the treatment of facial hyperpigmentation. ITR may serve as adjuvant for patients with such condition.

Ultrastructural characterization of damage in the basement membrane of facial melasma

The pathogenesis of melasma is not fully understood, and the role of skin basement membrane zone (BMZ) alterations in disease development and the maintenance of hypermelanogenesis are also poorly known. We performed a comparative study to characterize the ultrastructural alterations that occur in BMZ in melasma and adjacent normal skin, as well as we discuss the implications of these changes in the physiopathology of the disease. Pairs of facial skin biopsies (2 mm) from 10 women with melasma and normal skin (< 2 cm apart) were processed by Transmission Electronic Microscopy or immunohistochemistry for Melan-A counterstained with Periodic acid-Schiff stain. Cytoplasmic organelles (from keratinocyte or melanocyte), BMZ damage were assessed and melanocyte counting (total and pendulous) was done. There was greater amount of cytoplasmic organelles inside basal keratinocytes and melanocytes in melasma, as well as structural damaged areas in the lamina densa (disruptions, gaps, lower density and thinning) and anchoring fibrils (lamina lucida), compared to healthy adjacent skin. Areas with pendulous melanocytes are characterized by discontinuity of BMZ ultrastructure. The prominence of cytoplasmic organelles from melanocytes and keratinocytes evidences the involvement of both cell groups in melasma. The damage in the lamina densa and lamina lucida suggest the role of upper dermis injury/repair process in the pathogenesis of the disease.

Is There a Correlation between Severity of Melasma and Quality of Life?

BACKGROUND:

Melasma is a common chronic acquired hyper melanosis. It has significant impacts on appearance, psychosocial and emotional distress, hence reducing the quality of life of the affected patients. Melasma quality of life scale (MelasQoL) is a new quality of life (QoL) questionnaire consists of 10 questions, scored from 1 to 7, with higher index scores indicating poor QoL. The severity of melasma can be assessed by the Melasma Area and Severity Index (MASI) score.

AIM:

We aimed to determine the correlation between the severity of melasma (MASI score) and quality of life.

MATERIAL AND METHODS:

This was a cross-sectional analytic study involving 30 subjects with melasma. The diagnosis was made based on history, clinical features and by Wood’s lamp examination. MASI score was determined to assess the severity of melasma. Subjects answered 10 items of MelasQol questionnaire. All collected data were processed and statistically analysed by Spearman correlation test to determine the association of MASI score with MelasQoL. Association of quality of life with clinical pattern and depth of lesion were analysed by Mann Whitney test.

RESULTS:

There was no significant correlation between MASI score and MelasQoL (p = 0.797; r = 0.049). Likewise, there was no association of quality of life with clinical pattern type (p = 0.12) and depth of lesion (p = 0.92).

CONCLUSION:

There was no significant correlation between the MASI score and quality of life.

Profile of dermatological consultations in Brazil (2018)

BACKGROUND

Dermatological diseases are among the primary causes of the demand for basic health care. Studies on the frequency of dermatoses are important for the proper management of health planning.

OBJECTIVES

To evaluate the nosological and behavioral profiles of dermatological consultations in Brazil.

METHODS

The Brazilian Society of Dermatology invited all of its members to complete an online form on patients who sought consultations from March 21-26, 2018. The form contained questions about patient demographics, consultation type according to the patient's funding, the municipality of the consultation, diagnosis, treatments and procedures. Diagnostic and therapeutic decisions were compared between subgroups.

RESULTS

Data from 9629 visits were recorded. The most frequent causes for consultation were acne (8.0%), photoaging (7.7%), nonmelanoma skin cancer (5.4%), and actinic keratosis (4.7%). The identified diseases had distinct patterns with regard to gender, skin color, geographic region, type of funding for the consultation, and age group. Concerning the medical conducts, photoprotection was indicated in 44% of consultations, surgical diagnostic procedures were performed in 7.3%, surgical therapeutic procedures were conducted in 19.2%, and cosmetic procedures were performed in 7.1%.

STUDY LIMITATIONS

Nonrandomized survey, with a sample period of one week.

CONCLUSION

This research allowed us to identify the epidemiological profiles of the demands of outpatients for dermatologists in various contexts. The results also highlight the importance of aesthetic demands in privately funded consultations and the significance of diseases such as acne, nonmelanoma skin cancer, leprosy, and psoriasis to public health.

Tranexamic Acid for Adults with Melasma: A Systematic Review and Meta-Analysis

Objective

Melasma is a highly prevalent, chronic, and pigmentary disorder. This systematic review aims to evaluate the efficacy and safety of tranexamic acid (TA) for the treatment of adults with melasma.

Methods

We independently searched 3 databases from beginning to 26 April, 2018. The study included 21 eligible trials. Two writers extracted data at the same time independently. Study outcomes were calculated by standardized mean differences (SMD) with 95% confidence intervals (CIs). All statistical analyses were performed using Review Manager Version 5.3 and STATA Version 15.1.

Results

The combined results showed that the use of TA was associated with reduced Melasma Area and Severity Index (MASI) and Melanin Index (MI). No significant difference in Erythema Index (EI) was observed with TA treatment. Side effects were minor, with a few cases reporting mild gastrointestinal reaction, oligomenorrhoea, hypopigmentation, urticarial rash, and skin irritation xerosis.

Conclusion

The meta-analysis suggested that TA treatment appeared to be a promising therapeutic approach for melasma.

Complex segregation analysis of facial melasma in Brazil: evidence for a genetic susceptibility with a dominant pattern of segregation

Despite high prevalence, the etiopathology of melasma is not fully understood. Nevertheless, many factors have been associated with the disease, including: sun exposure, sex steroids hormones, drugs, stress, and pregnancy. The high occurrence within familiars (40-60%) suggests a genetic predisposition to the disease. This study explored, through complex segregation analysis (CSA), the inheritance model that best fit the family segregation pattern of facial melasma when accounting for the main epidemiological risk factors. We evaluated 686 subjects from 67 families, and 260 (38%) of them had facial melasma. The CSA model, adjusted for age, skin phototype, sex, sun exposure at work, hormonal oral contraceptive, and pregnancy, evidenced a genetic component that was best fitted to a dominant pattern of segregation. Melasma results from an interaction between exposure factors (e.g. pregnancy, hormones, and sun exposure) over genetically predisposed individuals.

Development and validation of a multidimensional questionnaire for evaluating quality of life in melasma (HRQ-melasma)

BACKGROUND

Melasma has a major impact on quality of life. MELASQoL is the only validated specific psychometric instrument to evaluate melasma QoL.

OBJECTIVE

To develop and validate a multidimensional questionnaire for evaluating quality of life related to facial melasma.

METHODS

Cross-sectional study performed in 2 institutions (public and private) from Brazil. Two focus groups were carried out: 5 board-certified dermatologists and 10 melasma patients, indicating the dimensions and significant units of melasma QoL. The preliminary questionnaire with 49 itens was applied to 154 facial melasma patients. Item reduction was performed by Rasch analysis. Parallel evaluations of clinical (MASI), demographic, and QoL aspects (MELASQoL, DLQI) were performed. The dimensional structure was assessed by confirmatory factor analysis. Temporal stability was tested in a subgroup of 42 individuals within 7-14 days.

RESULTS

The mean (SD) age of the 154 interviewed subjects was 39±8 years, and 87% were females. The median (p25-p75) DLQI and MELASQoL were: 2 (1-6) and 30 (17-44). HRQ-Melasma consisted of 19 items distributed in 4 dimensions: Physical/Appearance, Social/Professional, Psychological, and Treatment. Cronbach's alpha for HRQ-Melasma was 0.96, and >0.74 for each dimension. There was high correlation between HRQ-Melasma and DLQI and MELASQoL (rho=0.80 and 0.83), but modest with MASI (rho=0.35). Dimensional structure of HRQ-Melasma was stated by confirmatory factor analysis coefficients. Test-retest analysis disclosed an intraclass correlation coefficient of 0.91 (p<0.01).

STUDY LIMITATIONS

Single-center study.

CONCLUSIONS

A specific instrument to evaluate QoL in melasma with multidimensional characteristics was developed and validated, with appropriate psychometric performance.

Evaluation Instruments for Quality of Life Related to Melasma: An Integrative Review

The aim of this study was to analyze scientific production concerning the validation and cultural adaptation of quality of life evaluation instruments for patients with melasma and to offer a critical reflection on these methods. A literature review was performed based on a search of the Web of Science, Bireme, PubMed, Elsevier Scopus, and Google Scholar databases. All published articles from indexed periodicals in these electronic databases up to December 2015 were included. Eight articles were identified, of which only one (12.5%) referred to the development and validation of a specific instrument for evaluation of the quality of life of melasma patients. An additional six articles (75%) referred to transcultural adjustment and validation of the same instrument in other languages, and another (12.5%) article reported the development of a generic instrument for evaluation of quality of life in patients with pigment disorders. This review revealed only one specific instrument developed and validated in different cultures. Despite being widely used, this instrument did not follow the classic construction steps for psychometric instruments, which paves the way for future studies to develop novel instruments.

Factors associated with quality of life in facial melasma: a cross-sectional study

BACKGROUND

Melasma is a common chronic focal hypermelanosis that affects photexposed areas as face, mainly in women at fertile age. It inflicts a significant impact in quality of life; nevertheless, quality of life scores (e.g. MELASQoL) are not strongly correlated with clinical severity (e.g. MASI) in facial melasma, suggesting that different factors can influence the perception of disease beyond the clinical extension or the intensity of pigmentation.

OBJECTIVES

To explore clinical and socio-demographic aspects that influences MELASQoL scores.

METHODS

Cross-sectional study enrolling 155 adults (>18 y.o.) with facial melasma. MELASQoL, MASI, clinical and demographic information were assessed. The associations among factors were explored by multivariable methods.

RESULTS

The mean (SD) age of the participants was 39 (8) years, and 134 (86%) were females. The correlation (Spearman's rho) between MELASQoL and MASI was 0.35 (P < 0.05). In a multivariate regression, MELASQoL score was associated (P ≤ 0.05) to MASI score (β = 0.6), lower income (β = 6.8), be single (β = 4.2) and low education level (β = 5.0). At multiple correspondence analysis, MASI, sex, marriage, education and income were associated with MELASQoL, as well as MASI was associated to skin phototypes, income and education level.

CONCLUSION

The perception of life quality impairment in melasma is influenced by low scholarly, low family income, single marital status and greater clinical severity.

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

Melasma is a common disorder of hyperpigmentation characterized by tan or brown macules and patches affecting sun-exposed areas, particularly the face. Melasma has been shown to have a significant impact on the quality of life and self-esteem of those affected. We interviewed six patients who were diagnosed with moderate-to-severe melasma with regard to the effect of their disorder on their self-esteem. All patients reported a significant negative effect on their quality of life and self-esteem. With successful therapy using a triple combination of cream and oral tranexamic acid to treat their melasma, all reported a marked improvement in self-esteem. Physicians who treat patients with melasma should be aware of its profound psychosocial effects and the improvement that successful melasma treatment can have on self-esteem.

Psychometrican analysis and dimensional structure of the Brazilian version of melasma quality of life scale (MELASQoL-BP)

Background

Although asymptomatic, melasma inflicts significant impact on quality of life. MELASQoL is the main instrument used to assess quality of life associated with melasma, it has been validated in several languages, but its latent dimensional structure and psychometric properties haven´t been fully explored.

Objectives

To evaluate psychometric characteristics, information and dimensional structure of the Brazilian version of MELASQoL.

Methods

Survey with patients with facial melasma through socio-demographic questionnaire, DLQI-BRA, MASI and MELASQoL-BP, exploratory and confirmatory factor analysis, internal consistency of MELASQoL and latent dimensions (Cronbach's alpha). The informativeness of the model and items were investigated by the Rasch model (ordinal data).

Results

We evaluated 154 patients, 134 (87%) were female, mean age (± SD) of 39 (± 8) years, the onset of melasma at 27 (± 8) years, median (p25-p75) of MASI scores , DLQI and MELASQoL 8 (5-15) 2 (1-6) and 30 (17-44). The correlation (rho) of MELASQoL with DLQI and MASI were: 0.70 and 0.36. Exploratory factor analysis identified two latent dimensions: Q1-Q3 and Q4-Q10, which had significantly more adjusted factor structure than the one-dimensional model: Χ2 / gl = 2.03, CFI = 0.95, AGFI = 0.94, RMSEA = 0.08. Cronbach's coefficient for the one-dimensional model and the factors were: 0.95, 0.92 and 0.93. Rasch analysis demonstrated that the use of seven alternatives per item resulted in no increase in the model informativeness.

Conclusions

MELASQoL-BP showed good psychometric performance and a latent structure of two dimensions. We also identified an oversizing of item alternatives to characterize the aggregate information to each dimension.

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

Background:

Melasma Area and Severity Index (MASI), the scoring system in melasma, needs to be refined.

Aims and Objectives:

To propose a more practical scoring system, named as Melasma Severity Index (MSI), for assessing the disease severity and treatment response in melasma.

Materials and Methods:

Four dermatologists were trained to calculate MASI and also the proposed MSI scores. For MSI, the formula used was 0.4 (a × p²) l + 0.4 (a × p²) r + 0.2 (a × p²) n where “a” stands for area, “p” for pigmentation, “l” for left face, “r” for right face, and “n” for nose. On a single day, 30 enrolled patients were randomly examined by each trained dermatologist and their MASI and MSI scores were calculated. Next, each rater re-examined every 6^th patient for repeat MASI and MSI scoring to assess intra- and inter-rater reliability of MASI and MSI scores. Validity was assessed by comparing the individual scores of each rater with objective data from mexameter and ImageJ software.

Results:

Inter-rater reliability, as assessed by intraclass correlation coefficient, was significantly higher for MSI (0.955) as compared to MASI (0.816). Correlation of scores with objective data by Spearman's correlation revealed higher rho values for MSI than for MASI for all raters.

Limitations:

Sample population belonged to a single ethnic group.

Conclusions:

MSI is simpler and more practical scoring system for melasma.

Nucleic acid delivery into skin for the treatment of skin disease: Proofs-of-concept, potential impact, and remaining challenges

Nucleic acids (NAs) hold significant potential for the treatment of several diseases. Topical delivery of NAs for the treatment of skin diseases is especially advantageous since it bypasses the challenges associated with systemic administration which suffers from enzymatic degradation, systemic toxicity and lack of targeting to skin. However, the skin's protective barrier function limits the delivery of NAs into skin after topical application. Here, we highlight strategies for enhancing delivery of NAs into skin, and provide evidence that translation of topical NA therapies could have a transformative impact on the treatment of skin diseases.

Melasma and assessment of the quality of life in Brazilian women

BACKGROUND

Melasma is a chronic, acquired hyperpigmentation disease on sun-exposed areas of the skin, which affects patients' quality of life.

OBJECTIVE

To assess the impact on the quality of life of women living in Florianópolis, Brazil, through questionnaire (MelasQol), and investigate the clinical aspects and risk factors for melasma, correlating them with the MelasQol scores.

METHODS

This study was performed on 51 melasma patients cared for at the University Hospital of the Universidade Federal de Santa Catarina. The variables included were: age, gender, age of onset of melasma, Fitzpatrick phototype (I-VI), duration and family history of melasma, onset of melasma during pregnancy, use of hormonal contraceptive, thyroid disorder and distribution of melasma. The MelasQoL questionnaire, validated for Brazilian Portuguese (MelasQoL-BP), was applied.

RESULTS

The mean age was 38.43±6.75 years. All patients were women. The most common Fitzpatrick skin phototypes were III (49.02%) and IV (33.33%). Melasma had a mean age of onset of 29.18±7.05 years and a mean duration of 9.25±6.18 years. The majority of patients did not have familial history of melasma (50.98%). Melasma onset was associated with pregnancy (45.10%). The MelasQoL-BP analysis revealed significant emotional impact on patients, such as feeling bothered (94.11%), frustrated and embarrassed (64.71%), and depressed (52.94%) about their skin appearance, as well as unattractive (78.43%). No social impact was observed (P>0.05).

CONCLUSION

Melasma has a strong emotional impact on quality of life, resulting especially from feelings about skin appearance.

Translation, cross-cultural adaptation and validation of the vitiligo-specific health-related quality of life instrument (VitiQoL) into Brazilian Portuguese

BACKGROUND:

Vitiligo, although asymptomatic, highly compromises patients' quality of life (QoL). Therefore, an adequate evaluation of QoL is essential.

OBJECTIVES:

Translation, cultural adaptation and validation of VitiQol (Vitiligo-specific health-related quality of life instrument) into Brazilian Portuguese.

METHODS:

The study was conducted in two stages; the first stage was the translation and cultural/linguistic adaptation of the instrument; the second stage was the instrument's validation.

RESULTS:

The translated VitiQol showed high internal consistency (Cronbach alpha = 0.944) and high test-retest reliability and intraclass correlation coefficient=0.95 (CI 95% 0.86 - 0.98), p<0.001. There was no statistically significant difference between the means of the first completion of the VitiQoL questionnaire and the retest, p = 0.661. There was a significant correlation between VitiQoL and DLQI (r = 0.776, p <0.001) and also between VitiQoL-PB and subjects' assessment of the severity of their disease (r = 0.702, p <0.001).

CONCLUSIONS:

The impact of vitiligo on the QoL of Brazilian patients can be assessed by a specific questionnaire.

Melasma: a clinical and epidemiological review

Melasma is a chronic acquired hypermelanosis of the skin, characterized by irregular brown macules symmetrically distributed on sun-exposed areas of the body, particularly on the face. It is a common cause of demand for dermatological care that affects mainly women (especially during the menacme), and more pigmented phenotypes (Fitzpatrick skin types III-V). Due to its frequent facial involvement, the disease has an impact on the quality of life of patients. Its pathogeny is not yet completely understood, although there are some known triggering factors such as sun exposure, pregnancy, sexual hormones, inflammatory processes of the skin, use of cosmetics, steroids, and photosensitizing drugs. There is also a clear genetic predisposition, since over 40% of patients reported having relatives affected with the disease. In this manuscript, the authors discuss the main clinical and epidemiological aspects of melasma.

Measuring melasma patients' quality of life using willingness to pay and time trade-off methods in Thai population

BACKGROUND

Melasma is a common hyperpigmentation disorder that has a significant effect on an individual's quality of life. However, there is no preference-based measurement that reflects quality of life in patients with melasma. The objective of this study was to assess the impact of melasma on quality of life by using a health status measurement - the Dermatology Life Quality Index (DLQI) - and a preference-based measurement - Willingness to Pay (WTP) and Time Trade-Off (TTO).

METHODS

A cross-sectional descriptive study was conducted. Seventy-eight patients with melasma who attended the melasma clinic at Siriraj Hospital from February to March 2009 were recruited in this study. The Thai version of the DLQI, questionnaires about WTP, standard TTO, and daily TTO were used to assess patients' quality of life.

RESULTS

Seventy-seven (98.7%) patients were female with a mean age of 47.8 ± 7.9 years. The mean health utility based on standard TTO was 0.96. The utility obtained by the daily TTO method was 0.92 and was significantly correlated with an economically inactive occupation (p < 0.05). The mean monthly WTP for the most effective treatment was 1,157 baht (7.2% of monthly income), ranging from 100 to 5,000 baht (1 USD ~ 35.1 baht). The WTP was significantly correlated with monthly personal income and the total DLQI score.

CONCLUSION

The WTP method could be a useful tool with which to measure the quality of life of patients with melasma.

Melasma: a comprehensive update: part I

Melasma is a common disorder of hyperpigmentation affecting millions of people worldwide. While it is thought to be triggered or exacerbated by sun exposure and hormones, much remains to be understood about its pathogenesis. A thorough understanding of the etiology of melasma and the research tools available to study this condition are crucial to enhancing management and developing novel targeted therapies of this often frustrating condition.