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

Body dysmorphic disorder symptoms in patients with melasma

BACKGROUND

Body dysmorphic disorder (BDD) is a psychiatric condition characterized by extreme preoccupation with non-existent or minor defects in appearance, disrupting daily functioning. Melasma is a common concern among BDD patients with dermatological conditions. This study aimed to estimate the incidence and characteristics of BDD in patients with melasma, and compare the psychological condition of patients and age- and sex-matched healthy controls.

METHODS

Patients with melasma and healthy controls were screened using the BDD Questionnaire (BDDQ), Self-rating Anxiety Scale (SAS), and Self-rating Depression Scale (SDS). A questionnaire was administered to collect demographic information and clinical characteristics. Standard statistical tests were conducted, such as descriptive analysis, chi-square, and nonparametric tests. The level of statistical significance for all tests was set at a P < 0.05.

RESULTS

Among the 470 patients with melasma included in the study, 53 were positive for BDDQ in the preliminary screening and were associated with a history of treatment, higher Melasma Area and Severity Index (MASI), and Melasma Quality of Life (MELASQoL) scores, and higher SAS and SDS scores. The positive rate of BDDQ ranged from 0.4%, using the most stringent criteria to assess melasma severity, to 11.3%, without using objective criteria. Compared to healthy controls, patients with melasma had a higher positive rate of BDDQ and higher SAS and SDS scores.

CONCLUSION

In patients with melasma who exaggerate the severity of the disease, psychiatric treatment and the patient-physician relationship have a positive effect. This study assessed the positive rate of BDDQ in melasma and proposed the feasibility of psychiatric treatment for patients with melasma.

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

BACKGROUND

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

AIMS

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

PATIENTS/METHODS

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

RESULTS

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

CONCLUSIONS

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

Carotenoids in red fruit (Pandanus conoideus Lam.) have a potential role as an anti‑pigmentation agent (Review)

Melasma is a persistent condition characterized by excessive melanin production in the skin. The management of melasma necessitates a protracted treatment duration, which is associated with diminished levels of patient satisfaction. One effective strategy for mitigating occurrence of melasma is consumption of nutricosmetics with depigmentation properties. The present review aimed to investigate the potential of red fruit as a depigmentation agent. Carotenoids serve a crucial role in human nutrition as a precursor to vitamin A. Carotenoids serve as scavengers of reactive oxygen species generated by ultraviolet radiation. Carotenoids promote skin health. Red fruit, a fruit originating from Papua (Indonesia) has anti-pigmentation properties associated with its ability to block melanogenesis through various protein pathways such as PKA, ERK, and AKT signaling pathways. The consumption of food rich in carotenoids, such as red fruit, has advantageous properties to reduce hyperpigmentation and skin brightening.

Prevalence of depression in melasma: a systematic review and meta-analysis

Background

Due to cosmetic disfigurement, melasma can negatively affect the quality of life and emotional and mental health, further leading to depression.

Objective

Prevalence rates of depression in patients with melasma vary widely across studies. The aim of this systematic review and meta-analysis was to estimate the prevalence of depression among melasma patients.

Methods

The PubMed, Embase, Web of Science, and Scopus databases were searched to identify articles evaluating the prevalence of depression in melasma patients from their inception to 12 July 2023. Studies were reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and a meta-analysis was performed using the Stata 14.0 software.

Results

Sixteen studies met the eligibility criteria out of the 859 studies, containing a total of 2,963 melasma patients for this systematic review and meta-analysis. Meta-analyses revealed that the pooled prevalence of depression among patients with melasma was 43.4% (95% CI 30.5-56.2%, Q-value = 808.859, d.f. = 15, p < 0.001, tau2 = 0.065, I2 = 98.1%). The meta-regression found that the publication year, sample size, and study quality were not significant moderators for the observed heterogeneity in prevalence. A subgroup analysis according to depression assessment methods showed that the prevalence of depressive disorders was 24.2% (95% CI 16.8-31.6%), and the prevalence of depressive symptoms was 45.1% (95% CI 31.2-59.0%). A subgroup analysis by geographic regions showed that patients in Asia had the highest prevalence of depression at 48.5% (95% CI 26.0-71.0%), compared to other regions. A subgroup analysis by study design showed that the prevalence of depression in case-control studies was almost identical to cross-sectional studies. In the case of OR, the pooled OR of depression between patients with melasma and health controls was 1.677 (95% CI 1.163-2.420, p = 0.606, I2 = 0.0%).

Conclusion

The prevalence of depression was relatively high in patients with melasma, and there was a correlation between melasma and depression, encouraging clinicians to screen for depression in their patients and providing a combination of physical and psychosocial support. If necessary, they should be referred to formal mental health services to seek professional psychological intervention.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, CRD42022381378.

Awareness of sun exposure risks and photoprotection for preventing pigmentary disorders in Asian populations: Survey results from three Asian countries and expert panel recommendations

BACKGROUND

In this article, we review and discuss the photoprotection behavior of Asians based on the literature, along with a subanalysis of an original online survey, and make recommendations to optimize photoprotection for Asian populations to prevent photoaging and pigmentary disorders.

METHODS

An international panel of eight dermatologists from Asia (China, Korea, Japan, Singapore, Indonesia, and Vietnam) met to discuss sunscreen photoprotection for Asian patients. Additionally, a subanalysis of an online survey by 3000 respondents from three Asian countries (China, Indonesia, and Japan) investigated general public awareness and attitudes to sun exposure.

RESULTS

A pre-meeting survey of the eight experts from Asia showed key concerns of Asian patients consulting dermatologists are pigmentary disorders, especially actinic/senile lentigo, post-inflammatory hyperpigmentation, melasma, vitiligo, and Hori's nevus. The survey subanalysis of participants from China, Indonesia, and Japan with predominantly Fitzpatrick skin types (FST) II to IV revealed that they are particularly concerned about sun exposure causing photoaging and pigmentary disorders. Most of the respondents indicated they have limited knowledge on sunlight radiation and appropriate sunscreen protection factors. Only 22%, 13%, and 3% for China, Indonesia, and Japan, respectively, systematically use multiple protective measures (using sunscreen, avoiding midday sun, staying in the shade, wearing a hat, protective clothing, and sunglasses) when exposed to the sun.

CONCLUSIONS

Further education is needed for Asian populations on the importance of comprehensive daily photoprotection, including broad-spectrum sunscreen, with high UVA and visible light protection, to reduce and prevent photoaging and pigmentary disorders.

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.

A randomized, open-label study to compare two different dosing regimens of oral tranexamic acid in treatment of moderate to severe facial melasma

Oral tranexamic acid (TXA) demonstrates promising results in melasma management. However, no clear consensus on the dosing and duration of maintenance doses of TXA therapy in melasma exists. In this study, we intend to evaluate and compare the efficacy of two different TXA dosing regimens in patients with melasma using the mMASI score. This was a randomized, open-label study wherein 50 patients (age > 18 years) with moderate to severe melasma were randomized into group A (250 mg TXA twice a day) and group B (500 mg TXA twice a day). Treatment was administered for 12 weeks and later followed up 4-weekly for next 12 weeks. The primary outcome measure was proportion of patients achieving 75% reduction in modified Melasma area and severity index (mMASI-75) at 12 weeks from baseline, reduction in mMASI and melasma quality of life (MelasQOL) score at 12 and 24 weeks. To assess the rate of relapse by end of 12 weeks post-treatment. Among 50 patients, proportion of patients achieving mMASI-75 at 12 weeks were 20% and 25% in group A and B, respectively (p-0.71). Both groups showed a significant reduction in mean mMASI (4.8 ± 2.2 in group A and 6.8 ± 3.4 in group B; p-0.02) at 12 weeks of treatment. mMASI remained stable after 12 weeks of follow-up and was 4.9 ± 2.43 and 4.93 ± 2.85 in group A and B, respectively (p-0.97). The mean percentage reduction in MelasQOL in group A and B were 41.8 ± 15.3 and 29.5 ± 21.5, respectively (p-0.03). No adverse effects were observed in both groups. Relapse rates was very less and comparable between both groups. Thus, we conclude that both dosing regimens showed comparable efficacy in terms of mMASI reduction at 12-weeks and the improvement achieved was well maintained even after 12-weeks of discontinuing treatment with very few patients relapsed. Hence, lower doses of TXA are equally effective and safe compared to higher doses and not all patients might require tapering or dosing maintenance.

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).

Clinical Applications of Polypodium leucotomos (Fernblock®): An Update

Exposure to sun radiation leads to higher risk of sunburn, pigmentation, immunosuppression, photoaging and skin cancer. In addition to ultraviolet radiation (UVR), recent research indicates that infrared radiation (IR) and visible light (VIS) can play an important role in the pathogenesis of some of these processes. Detrimental effects associated with sun exposure are well known, but new studies have shown that DNA damage continues to occur long after exposure to solar radiation has ended. Regarding photoprotection strategies, natural substances are emerging for topical and oral photoprotection. In this sense, Fernblock^®, a standardized aqueous extract of the fern Polypodium Leucotomos (PLE), has been widely administered both topically and orally with a strong safety profile. Thus, this extract has been used extensively in clinical practice, including as a complement to photodynamic therapy (PDT) for treating actinic keratoses (AKs) and field cancerization. It has also been used to treat skin diseases such as photodermatoses, photoaggravated inflammatory conditions and pigmentary disorders. This review examines the most recent developments in the clinical application of Fernblock^® and assesses how newly investigated action mechanisms may influence its clinical use.

Combination Topical Tranexamic Acid and Vitamin C for the Treatment of Refractory Melasma

BACKGROUND

Melasma is a widespread condition that affects people of many ethnicities and is prevalent in the Middle East. To date, the therapeutic arsenal is still not effective, especially in countries with high ultraviolet light index. New treatment options are needed.

OBJECTIVE

The aim of this pilot study was to assess the efficacy of topical tranexamic acid (TA) 2% combined with vitamin C 2% in the treatment of resistant melasma in the Mediterranean region.

METHODS

This prospective interventional pilot study included 10 women, aged 18 to 55 years, with resistant melasma. Intervention consisted in application of a topical formulation containing 2% TA and 2% vitamin C, every night for eight weeks. The primary outcome was the Melasma Area and Severity Index (MASI) score measured at baseline and at Weeks 4 and 8. Melasma Quality of Life Scale (MelasQoL) and Physician Global Assessment (PGA) were used at baseline and at Weeks 4 and 8 of treatment, and they were set as the secondary outcomes.

RESULTS

The mean MASI score varied from 12.76±3.91 at baseline to 7.00±4.85 at Week 4 (p<0.01) then to 3.39 ± 1 at Week 8 (p=0.03). The mean MelasQoL decreased from 35.2 ± 16.03 at baseline to 28.8 ± 12.96 at Week 4 (p<0.01) then to 24.9±13.96 at Week 8 (p=0.14). The PGA increased between Weeks 4 and 8 passing from 2.2±0.79 to 2.4±1.07. No major side effects were reported.

CONCLUSION

Our pilot study demonstrated the possibility of a topical combination of TA 2% and vitamin C 2 %, which may be a useful therapeutic strategy in the treatment of resistant melasma in the Middle east, a region of the world with high UV index. This combination treatment is a safer alternative to dangerous bleaching treatments that are still being used.

Efficacy of topical vitamin C in melasma and photoaging: A systematic review

BACKGROUND

Vitamin C is a micronutrient present in high concentrations in normal skin and a highly prescribed cosmeceutical, well known for protecting against ultraviolet-induced pigmentation and regulating collagen production. However, there is a lack of studies evaluating the efficacy of topical vitamin C in photoaging and melasma, with this systematic review being the first to assess the existing evidence.

AIM

This systematic review aims to assess whether topical vitamin C could be effective in reversing photoaging signs and treating melasma.

METHODS

Prospective, randomized controlled trials assessing protocols with topically applied vitamin C in patients with melasma or photodamage were searched in Medline, CENTRAL, and Scopus databases until the 12th of May 2022. Risk of bias was conducted in accordance with Cochrane Collaboration's tool for assessing the risk of bias in randomized trials, using RevMan 5.0.

RESULTS

Seven publications were included, with 139 volunteers in total. Studies that evaluated the topography of skin indicated that the treated skin appeared smoother and less wrinkled, which was supported by biopsies data. On objective assessments of pigmentation, there was a significant lightening of the skin treated. Hydration improved equally in the vitamin C and placebo-treated sites.

CONCLUSIONS

This study revealed that vitamin C is effective in treating uneven, wrinkled skin and has depigmenting properties, but long-term use may be needed to achieve noticeable changes. Q-switched Nd:YAG laser-associated protocols appear beneficial in enhancing vitamin C effects. Topical vitamin C may be a suitable alternative for melasma and photoaging, but more studies are needed to confirm these results and assess the ideal vitamin C concentration.

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.