Histological changes in facial melasma after treatment with triple combination cream with or without oral tranexamic acid and/or microneedling, a randomised clinical trial

A Scoping Review on Melasma Treatments and Their Histopathologic Correlates

Melasma is an incredibly common dyschromic disorder, mostly impacting women with skin of color. There are three variants of melasma based on the depth of pathologic involvement: epidermal, mixed, and dermal. While there are many treatments for melasma, there is a paucity of research on melasma treatments and their dermatopathological correlates. A scoping review was conducted of all human trials on melasma with histopathologic analysis, including 37 trials in the final analysis. Most studies were conducted on women with a Fitzpatrick skin type of III or greater. Strong histologic evidence supports the utilization of retinols/retinoids for epidermal melasma and microneedling for dermal melasma. There is a paucity of trials conducted on melasma utilizing histologic correlates, and fewer still that are comprehensive to include analyses on quality of life.

Value of Q-switched 755-nm alexandrite laser combined with topical tranexamic acid in the treatment of melasma

OBJECTIVE

To explore the clinical value of Q-switched 755-nm alexandrite laser combined with topical tranexamic acid in treating melasma.

METHODS

A total of 121 melasma patients treated at AIST Medical Cosmetology Hospital from July 2022 to January 2024 were retrospectively included. They were divided into two groups: the Laser Treatment Group (LTG, n=61), receiving Q-switched 755-nm alexandrite laser combined with topical tranexamic acid, and the Control Treatment Group (CTG, n=60), receiving only topical tranexamic acid. Clinical efficacy, skin scores before and after treatment, laboratory indicators, melanin index, dermoscopic scores for pigmentation and vascular components, dermoscopic typing improvement, adverse reactions, and recurrence rates were compared.

RESULTS

The treatment efficacy rate was 93.44% in the LTG, significantly higher than 81.67% in the CTG (P<0.05). After treatment, the LTG showed significantly lower Melasma Area and Severity Index (MASI) scores, skin lesion color, and area scores compared to the CTG (all P<0.05). No significant differences were found in malondialdehyde (MDA) and superoxide dismutase (SOD) levels (both P>0.05). The LTG had a lower melanin index and dermoscopic scores for telangiectasia and perifollicular pigmentation than the CTG (all P<0.05). The incidence of adverse reactions in the LTG was 11.48%, significantly lower than 40.00% in the CTG (P<0.05). The LTG also had a lower recurrence rate of 1.64% at 6-month follow-up, compared to 10.00% in the CTG (P<0.05).

CONCLUSION

Q-switched 755-nm alexandrite laser combined with topical tranexamic acid is highly effective in treating melasma, improving clinical symptoms, reducing oxidative stress and inflammation, and yielding better results in vascular proliferation and pigmentation. The treatment also demonstrated a low recurrence rate, suggesting its potential for broader use.

Review of Applications of Microneedling in Melasma

BACKGROUND

Melasma, a common skin pigmentation disease, can negatively impact patients' mental health, social interactions, and physical appearance. Although we now have several treatments accessible, such as medicines, chemical peels, and phototherapy, which can help ease symptoms to some extent, the requirement for a long-term effective and safe treatment for patients is far from met. In the face of this problem, microneedling, as an innovative treatment, provides a new avenue for treating melasma. Although microneedling has been extensively investigated for treating other skin issues such as inflammation, scarring, and photoaging, research into its use in melasma treatment is still in its early stages.

OBJECTIVE

This study aimed to gather and assess clinical information on microneedling's effectiveness in treating melasma, covering research gaps and serving as a beneficial reference for clinical therapy.

METHODS

We searched PubMed, Cochrane, Scopus, Embase, and Web of Science databases for articles with the keywords "microneedling," "percutaneous collagen induction", and "melasma." Following a thorough assessment, we selected 64 clinical studies that matched the requirements for in-depth analysis.

RESULTS

After thoroughly reviewing these data, we concluded that microneedling has tremendous potential for treating melasma. Microneedling can significantly improve treatment outcomes, especially when paired with additional therapies such as topical medicines or phototherapy.

CONCLUSION

Overall, the evidence reported in this study demonstrates that microneedling is an essential advancement in melasma treatment. Not only can it improve the efficacy of topical drugs and other treatment modalities, but it also has an excellent safety and tolerability profile, making it desirable to patients and clinicians. While the current findings are encouraging, more study is needed to refine treatment protocols, investigate the long-term consequences of microneedling, and establish it as the standard of care for melasma treatment. We anticipate that microneedling will play an increasingly important role in the future of melasma treatment, providing our patients with more hope and a broader choice of treatment alternatives.

Energy-Based Methods and Nanocarrier-Based Approaches for Melasma Treatment

Purpose

Melasma is a persistent skin condition caused by excessive melanin production, particularly affecting women's quality of life. It can result from various factors like sun exposure, genetics, hormones, medications, or inflammation. Effective melasma treatment requires products that can deeply penetrate the skin. The outermost skin layer, known as the stratum corneum (SC), plays a crucial role in delivering topical and transdermal drugs. Researchers have developed numerous strategies to enhance skin permeability and drug efficacy.

Methods

This review delves into energy-based techniques and nanocarrier systems for treating melasma, specifically focusing on improving drug delivery to the viable epidermis (EP) while overcoming the SC barrier.

Results

Physical methods offer benefits such as enhanced skin penetration but come with drawbacks like frequent visits, high costs, and the need for specialized equipment and skilled operators. Microneedle patches are gaining attention as a convenient physical treatment option for delivering multiple medications effectively, offering targeted delivery and minimal side effects. Nanocarrier systems like transferosomes demonstrate promise in enhancing skin penetration for treating melasma and skin hyperpigmentation. While they offer advantages such as high drug entrapment and improved bioavailability, challenges like stability issues and scalability hinder their widespread adoption.

Conclusion

Energy-based techniques enhance drug penetration but can lead to scarring and burns, while dissolvable micro-needles offer a convenient and effective alternative. Nano-drug carriers, like nanostructured lipid carriers (NLCs) and transferosomes, show promise for improved skin drug delivery with their flexible structures and enhanced penetration capabilities, yet further clinical research is needed for definitive conclusions.

Global research trends on melasma: a bibliometric and visualized study from 2014 to 2023

Melasma, a prevalent pigmentary disorder, is characterized by its complex etiology, propensity for recurrence, and resistance to treatment. However, there is currently no research on melasma through bibliometrics and visualisation. This study analyses the hotspots and trends in the field based on 2,709 publications from the Web of Science Core Collection (WOSCC). We carried out bibliometric analyses using Citespace software for different countries/regions, institutions, authors, and keywords. References were also analysed using VoSviewer. The results indicate that overall, there has been an increase in publications related to melasma since 2014. According to the analysis of the collaborative network diagram, the United States, Egyptian Knowledge Bank, and Benjakul Soottawat are the most contributing countries, institutions, and authors, respectively. Reference and keyword analyses have identified the pathogenesis and treatment of melasma as a prevalent topic in recent years. And how to find new treatment options and more effective therapeutic drugs is a future research trend. This is the first bibliometric and visual analysis of melasma-related literature to explore research hotspots and trends.

Tranexamic Acid Ameliorates Skin Hyperpigmentation by Downregulating Endothelin-1 Expression in Dermal Microvascular Endothelial Cells

BACKGROUND

Although reports suggest that tranexamic acid (TXA) has clinical benefits for melasma patients by oral, intralesional and topical treatment, the optimal route of TXA therapy and the underlying mechanism involved remain poorly defined.

OBJECTIVE

To compare the skin lightening effect between oral TXA and topical TXA and to dissect the molecular mechanisms using ultraviolet B (UVB)-induced hyperpigmentation mouse model, ex vivo cultured human skin explant, and cultured melanocytes (MCs) and endothelial cells.

METHODS

Melanin content and cluster of differentiation 31 (CD31)-positive cell numbers were measured in tail skins from UVB-irradiated mice treated by intragastral or topical TXA using immunofluorescent and Fontana-Masson staining. The conditioned medium (CM) was harvested from human umbilical vein endothelial cells treated with or without 3 mM TXA and was used to treat MCs for 48 hours. mRNA and protein levels of tyrosinase and microphthalmia-associated transcription factor were measured using quantitative real-time reverse transcription polymerase chain reaction and western blotting assays. HMB45- and CD31-positive cell numbers as well as melanin content were also examined in ex vivo cultured human skin explants.

RESULTS

The hyperpigmented phenotype were significantly mitigated in UVB-irradiated tail skin plus intragastral TXA-treated mice compared with mice treated with UVB only or with UVB plus topical TXA. CD31-positive cell numbers correlated with the anti-melanogenic activity of TXA therapy. The data from cultured cells and skin tissues showed that suppression of endothelin-1 (ET-1) in vascular endothelial cells by TXA reduced melanogenesis and MC proliferation.

CONCLUSION

Oral TXA outperforms topical TXA treatment in skin lightening, which contributes to suppression of ET-1 in dermal microvascular endothelial cells by TXA.

The efficacy and safety of microneedling with topical tranexamic acid for melasma treatment: A systematic review and meta-analysis

OBJECTIVE

Microneedling with topical tranexamic acid (TXA) is a novel treatment option for melasma; however, the efficacy and safety of this combined administration therapy is in controversial. This study is conducted to address this issue of this technique in melasma.

METHODS

An extensive literature review was performed to identify relevant trials, including randomized split-face studies, randomized controlled trials and prospective non-randomized split-face studies, comparing microneedling plus topical TXA to routine treatments or placebo. The primary outcomes were changes of the Melasma Area Severity Index (MASI)/modified MASI (mMASI)/hemi MASI between before and after treatment, as well as the changes between a particular treatment and microneedling plus TXA. The mean differences (MDs) and 95% confidence intervals (CIs) were calculated for the reduction of melasma severity scores from baseline to each time point. In contrast, the standard mean differences (SMDs) and 95% CIs were calculated for the differences in reduction in melasma severity scores between the experimental and control groups at each time point.

RESULTS

A total of 16 trials were included in the systematic review and data synthesis. The pooled analysis demonstrated that MASI, mMASI, and hemiMASI scores decreased significantly at 4 weeks (MD = 1.85; 95% CI = 1.15-2.54), 8 weeks (MD = 3.28; 95% CI = 2.31-4.24), 12 weeks (MD = 4.73; 95% CI = 2.79-6.50), 16 weeks (MD = 3.18; 95% CI = 1.50-4.85), and 20 weeks (MD = 3.20; 95% CI = 1.95-4.46) after treatment when compared with baseline. The reduction in melasma severity scores of microneedling with TXA group at 4 weeks was more significant than the routine treatment group (SMD = 0.97; 95% CI = 0.09-1.86), while insignificant at 8 weeks (SMD = 1.21; 95% CI = -0.17 to 2.59), 12 weeks (SMD = 0.63; 95% CI = -0.03 to 1.29), 16 weeks (SMD = 0.61; 95% CI = -2.85 to 4.07), or 20 weeks (SMD = 1.04; 95% CI = -1.28 to 3.36).

CONCLUSION

Despite the high heterogeneity across these studies, the current findings indicated that microneedling with topical TXA is an alternative treatment option for melasma treatment; and more well-designed studies are needed to confirm it.

Update on Melasma-Part II: Treatment

Melasma is a prevalent chronic relapsing pigmentary disorder that affects photoexposed areas, especially in women of childbearing age. Although there is currently no curative treatment available for melasma, this manuscript critically reviews the knowledge regarding photoprotection, topical and oral therapies, and procedures such as peelings, laser, and microneedling that represent the main strategies for control and prevention of this disease. As the pathogenesis of melasma is not entirely understood, there are prospects for the development of new therapeutic strategies that might act on the pathways that promote sustained pigmentation rather than merely decreasing melanin synthesis and removing melanin from the epidermis.

Update on Melasma-Part I: Pathogenesis

Melasma is a multifactorial dyschromia that results from exposure to external factors (such as solar radiation) and hormonal factors (such as sex hormones and pregnancy), as well as skin inflammation (such as contact dermatitis and esthetic procedures), in genetically predisposed individuals. Beyond hyperfunctional melanocytes, skin with melasma exhibits a series of structural and functional alterations in the epidermis, basement membrane, and upper dermis that interact to elicit and sustain a focal hypermelanogenic phenotype. Evolution in the knowledge of the genetic basis of melasma and the cutaneous response to solar radiation, as well as the roles of endocrine factors, antioxidant system, endothelium proliferation, fibroblast senescence, mast cell degranulation, autophagy deficits of the melanocyte, and the paracrine regulation of melanogenesis, will lead to the development of new treatments and preventive strategies. This review presents current knowledge on these aspects of the pathogenesis of melasma and discusses the effects of specific treatments and future research on these issues.