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Received: 27 April 2018    Revised: 17 October 2018    Accepted: 3 January 2019

DOI: 10.1111/jocd.12874

ORIGINAL CONTRIBUTION

Efficacy of mesotherapy with tranexamic acid and ascorbic acid

with and without glutathione in treatment of melasma: A split
face comparative trial

Fariba Iraji MD | Mojtaba Nasimi MD  | Ali Asilian MD | Gita Faghihi MD | 

Samaneh Mozafarpoor MD | Hossein Hafezi MD

Department of Dermatology, School of

Medicine, Isfahan University of Medical
Sciences, Isfahan, Iran
Correspondence
Mojtaba Nasimi, Department of
Dermatology, School of Medicine, Isfahan
University of Medical Sciences, Isfahan, Iran.
Email: mojtabanasimi@gmail.com
Abstract
Introduction: Melasma is a prevalent annoying skin hyperpigmentation disorder that
commonly involves reproductive‐aged females. Variety of treatments with contro‐
versial results has been recommended. The aim of the current study was to evaluate
combination therapy of tranexamic acid (TA) and vitamin C with and without glu‐
tathione with mesotherapy technique for treatment of melasma.
Methods and Materials: This is a randomized clinical trial study conducted on 30
patients referred to Dermatology Clinics. Patients were examined under wood lamp
in order of melasma type (epidermal, dermal, or mixed) determination. Then, patients
underwent melasma therapy using Cocktail A (TA 4 mg/mL; vitamin C 3% and glu‐
tathione 2%) on their right half of the face and Cocktail B (TA 4 mg/mL and vitamin C
3%) on their left half of the face, with mesotherapy technique. This procedure was
done for six times with 2‐week intervals. Patients' modified Melasma Area and
Severity Scoring (mMASI) was assessed at initiation and end of the study.
Results: According to mMASI score changes 12 weeks after intervention, both cock‐
tails had significant efficacy in reduction of mMASI score in each side. Mean of
mMASI in left side had decrease of 1.82 ± 0.88 (P‐value < 0.001) and in right side had
decrease of 3.046 ± 1.25 (P‐value < 0.001) from base line. Comparison between two
groups 12 weeks after treatment showed significantly more reduction (1.28 ± 0.64)
of mMASI score with cocktail A than B (P‐value < 0.001). Erythema, edema, and ec‐
chymosis was not significantly different among two cocktails (P‐value > 0.05).
Conclusion: Use of combination mesotherapy in treatment of melasma was accom‐
panied with appropriate outcomes regardless of type of agents but treatment with
glutathione containing cocktail A presented superior results compared with cocktail
of TA and vitamin C but not glutathione.

KEYWORDS
ascorbic acid, glutathione, melasma, mesotherapy, tranexamic acid

1 |  I NTRO D U C TI O N among those with darker skins. Melasma can affect a person's life neg‐
atively regarding his/her psychosocial or even emotional status.1
Melasma is a prevalent skin hyperpigmentation disorder that commonly Although studies have presented prevalence of this hyperpig‐
involves reproductive‐aged females. This disorder is more common mentation disorder in 5%‐70% of people, only 10% of affected cases

J Cosmet Dermatol. 2019;1–6. © 2019 Wiley Periodicals, Inc. |  1

wileyonlinelibrary.com/journal/jocd  
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2       IRAJI et al.
are males and most of women resenting from melasma are residence
2,3
of Asia and Latin America.
This hyperpigmentation disorder is commonly found on
sun‐exposed skin areas, and variety of patterns including cen‐
trofacial, malar, and mandibular has been presented by previous
studies. 3,4
Despite high prevalence of melasma, the main underlying etiol‐
ogy of this disorder is still under question. Genetic factors, UV ir‐
radiation exposure, pregnancy, oral contraceptives (OCP), thyroid
dysfunction, cosmetic products, phototoxic drugs, and antiepilep‐
tic drugs have been considered as possible etiologies of melasma
presentation.5
Variety of techniques in which it has been tried to confront with
mentioned factors above for treatment of this disorder has been
recommended. These techniques include use of sunscreens, laser
therapy, and use of hypopigmenting remedies mostly in combina‐
tion with other compounds such as tretinoin, local steroids, or local
peeling compounds.6
Plasmin activates following UV irradiation exposure. Tranexamic
acid (TA) is a plasmin inhibitor that acts by preventing adhesion of
plasminogen to keratinocyte. This procedure is accompanied with
less prostaglandin production and eventually reduction of mela‐
nocyte tyrosine kinase activity. There are limited studies in which
it has been stated that use of TA is accompanied with acceptable
outcomes and less adverse effects in comparison with peeling com‐
pounds for treatment of melasma.1,7,8
Vitamin C is another remedy used for melasma treatment as it
has been considered for a long time for freshness and sensuality of
skin and also it is considered to prevent melanine production.9
Recently, depigmentation characteristics of glutathione
have been discussed widely. This substance can be found over
the body and has various biological functions including skin de‐
pigmentation. Studies about effect and method of glutathione
use for melasma treatment are limited, and also outcomes are
controversial.10,11
Successful treatment of melasma may be achieved using combi‐
nation therapy of these depigmentation factors regarding synergism
action achievement. In addition, other significant factors including
cytotoxicity, solubility, skin absorption, and penetration should be
assessed as well.12
Considering what was mentioned above, in this study, we have
aimed to evaluate combination therapy of tranexamic acid, vitamin
C with and without glutathione using mesotherapy technique for
treatment of melasma.
2 |  M E TH O DS A N D M ATE R I A L S
This is a randomized clinical trial study conducted on 30 patients
referred to Dermatology Clinics of Isfahan University of Medical
Sciences with chief complaint of melasma during 2017.
Twenty‐ to fifty‐year‐old patients with Fitzpatrick II‐IV skin
type and symmetrical melasma were included, and those with
history of hormone therapy or OCP, antiepileptic, anti‐depres‐
sion, and hypo/hyper thyroid remedies use in recent 12 months
were excluded. In addition, those under anticoagulant therapy or
with coagulopathy, with active herpetic lesions, facial wart, ac‐
tive dermatosis and who presented hypersensitivity to adminis‐
tered substances, who were pregnant or lactating were excluded
as well.
Consent forms for participating and all needed information
about the study were given to the patients. This study was ap‐
proved based on 395716 code from Research Council and Ethics
Committee of School of Medicine of Isfahan University of Medical
Sciences.
Number of 38 patients was randomly selected for participation
in this study but eight of them were excluded due to missing follow‐
up visits. Study population formula has been presented in following.
Consort diagram is presented in Figure 1.
( )2 ( )
Z1− 𝛼 + Z1−𝛽
2
S21 + S22
n=
d2
Confidence interval = 95%, α = 0.05, Z1−𝛼 = 1.96, β = 0.6 (study
2
power was considered as 80%), Z1−β = 0.84, S1 = S2 = 16.7% and
d = 11.
At first, patients were examined under wood lamp in order of
melasma type (epidermal, dermal, or mixed) determination.1 Then, pho‐
tography was taken from all participants using a digital camera (Canon
Power Shot G12, Canon Components In; Saitama Prefecture, Japan).
In the next step, patients underwent melasma therapy using
Cocktail A (TA 4 mg/mL; vitamin C 3% and glutathione 2%;
Toskanicosmetics, Barcelona, Spain) on their right half of the face
and Cocktail B (TA4mg/mL and vitamin C 3%) (Toskanicosmetics) on
their left half of the face, with mesotherapy technique administrat‐
ing Mesomate device (Innovative Med Inc; Irvine, CA, USA). In this
technique, mesotherapy was done in one millimeter depth and with
distance of 1 mm using a 30‐gauge needle. This procedure was done
for five other times with 2‐week intervals.
After each session of mesotherapy, patients were questioned
about side effects including erythema, edema, and ecchymosis.
Prior to each session of mesotherapy, patients were evaluated
and examined. Then 12 weeks after study initiation, all patients un‐
derwent photography with similar digital camera again. Duration
of patients' follow‐ups was decided based on Guidelines for clini‐
cal trials in melasma that had recommended duration of 12 weeks
follow‐up.13
Severity of lesions was assessed using modified Melasma Area
and Severity Scoring (mMASI).14
In this method, patients' lesions were evaluated in four locations
of forehead, right malar, left malar, and chin considering two criteria
of involved area (A) and severity of darkness (D). Involved area score
is 0‐6 (0: lack of involvement, 1: <10%, 2: 10%‐29%, 3: 30%‐49%,
4: 50%‐69%, 5: 70%‐89% and 6: 90%‐100% involvement). Darkness
severity was scored as follows: 0: normal skin color; 1: extremely
mild pigmentation; 2: mild pigmentation; 3: moderate pigmentation;
IRAJI et al. |
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F I G U R E 1   Consort diagram of studied

cases

and 4: severe pigmentation. Thereafter, two criteria were calculated
using the following formula:
Total mMASI Score = Forehead 0.3 DA + Right Malar 0.3 DA
+ Left Malar 0.3 DA + Chin 0.1 DA
As we are examining two cocktails, in a split face manner, this
formula should be used:
mMASI Score = Forehead 0.15 DA + Right Malar∕Left Malar 0.3 DA
+ Chin 0.05 DA for each side.
All patients were prescribed to use sunscreen cream SPF30
(Arden, Tehran, Iran) during the study.
Prior to study initiation and at the end of 12th week, all patients
were visited and mMASI was assessed for them by the dermatolo‐
gist responsible for the study and also they were visited considering
postinflammatory pigmentation as well. Thereafter, within 12 weeks
(equals with 24 weeks after study initiation), patients were asked to
refer again for assessment of probable recurrence.
In addition, another target blinded dermatologist presented her as‐
sessment based on photographs taken at initiation and end of the study.
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4       IRAJI et al.
Also, patients were asked about their satisfaction of procedure
15
based on Patient Global Assessment (PGA) and scored 0‐10.
Then, data were analyzed with IBM SPSS20 (International Business
Machines Corporation [IBM], Armonk, NY, USA)—United States soft‐
ware. Descriptive data were reported in mean ± standard deviation.
For analytic data, independent t test, paired t test, chi‐square, and
ANOVA were used. P‐value of <0.05 was considered significant.
3 |   R E S U LT S
Number of 38 patients eligible for the study was included while 8
of them did not participate in follow‐up visits and were excluded.
Thus, the study was completed by 30 patients with mean age of
38.8 years. Five of patients had dermal, six had epidermal, and 19
others had mixed lesions. Erythema following mesotherapy was
66.7% in both sides of the face; edema was 50% among patients
treated with cocktail A (right side) and 36.7% for cocktail B (left
F I G U R E 2   Six different views of a patient resenting from melasma prior to mesotherpay
side); and ecchymosis was 40% in cocktail A‐ and 30% in cocktail
B–treated patients (P‐value > 0.05).
Mean score of mMASI prior to intervention of right side was
4.52 ± 1.90 and left side was 4.57 ± 1.85. No significant difference
was found (P‐value = 0.461).
Mean of mMASI score within 12 weeks after study initiation
had decrease of 1.82 ± 0.88 (P‐value < 0.001) in left side and had
decrease of 3.046 ± 1.25 (P‐value < 0.001) in right side.
Figures 2 and 3 are demonstrating effects of mesotherapy in a pa‐
tient prior to and within 12 weeks after treatment, respectively.
Mean of mMASI in 12th week after study initiation was
1.47 ± 0.77 in right side (cocktail A) and 2.75 ± 1.28 in left side (cock‐
tail B; P‐value<0.001) with significantly more reduction (1.28 ± 0.64)
of mMASI score with cocktail A than B (P‐value < 0.001; Table 1).
In addition, patients’ satisfaction based on PGA for right side was
8.77 ± 1.10 and for left side was 5.63 ± 1.15. There was significant dif‐
ference between patients’ satisfaction of two cocktails (P‐value < 0.001).
IRAJI et al. |
      5

While numerous people are resenting from this unruly hyperpigmen‐

tatory disorder, results of studies about approaches of melasma treatment
are incomplete and controversial; thus, efforts for finding the best, most
affordable, and most effective way of melasma treatment are going on.
As mentioned above, tranexamic acid (TA) is an agent that in‐
hibits plasmin activity and therefore can cause reduction of mela‐
nocyte tyrosine kinase activity.7 In a study conducted by Nashwa
Naeem Elfar et al on patients with melasma, they found that use of
TA is as successful as glycolic acid peeling while PIP presentation
by peeling was significantly less by use of TA.1 The other study in
this way conducted by Ji Ho Lee et al presented similar results of
intradermal microinjection of TA. Eventually, MASI score measured
by dermatologist at the end of the 8th and 12th weeks of the study
was improved statistically and also patients' satisfaction. In addition,
minimal side effects were presented as well.7
The other agent has been mentioned previously as a potential
agent for preserving skin freshness for a long time is vitamin C.
Liliana Elizabeth Espinal Perez et al have compared effects of me‐
lasma treatment with vitamin C vs its treatment with hydroquinone,
and they presented that although results of hydroquinone adminis‐
tration were better, patients under vitamin C treatment presented
acceptable outcomes in addition to less side effects of vitamin C.17
Glutathione as the other depigmentator agent has been used re‐
cently. Hypothesizes about depigmentatory effects of glutathione
include direct melanocyte tyrosine kinase inactivation, acting in inter‐
F I G U R E 3   That patient referred for follow‐ups within 12 wk mediation of altering eumelanin production to pheomelanin produc‐
after mesotherapy initiation tion, elimination of free radicals playing role in melanocyte tyrosine
kinase production and regulation of melanotoxic depigmentation fac‐
tors.18 In a study conducted in Thailand, they tried to examine use of
No postinflammatory pigmentation was detected among low‐dose oral glutathione in treatment of melasma and found that pa‐
patients. tients who underwent treatment with this agent presented significant
Then, patients referred again within next 12 weeks (24 weeks better results in comparison with those who were treated by placebo.
after study initiation). No recurrence and no improved response to It should be mentioned that their study duration was only 4 weeks and
therapy were observed. It should be mentioned that only 21 patients long‐term tolerability and side effects of oral glutathione use is not
out of 30 referred for the last follow‐up. recognized yet.10 The other study conducted by M Sriharsha et al as‐
sessed effects of local glutathione use in form of soap. They presented
that use of glutathione was accompanied with therapeutic response in
4 | D I S CU S S I O N lesions associated with UV irradiation exposure and hypothesized that
glutathione may affect melanogenesis but not existing lesions.19
Melasma is a prevalent annoying hyperpigmented skin disorder com‐ Similar to some studies that believe more significant effects
monly found among Asian and Latin American females. Etiology of of combination therapy than monotherapy,12 in the current study
this disorder is still under question; however various hypothesizes we assessed combination of mentioned agents (TA and vitamin
have been raised from genetic factor, exposure to UV irradiation, C) use with (group A) and without glutathione (group B). In our
hormonal dysfunctions to some drug remedies used by females. 2,16 study, 6 session mesotherapy of mentioned agents with intervals
of 2 weeks was accompanied with significant respond to therapy
TA B L E 1   mMaSI of patients at initiation and 12 wk after the regardless of type of remedies used for patients. In fact, meso‐
intervention therapy with combination of TA, vitamin C, and glutathione was
accompanied with appropriate melasma treatment and the results
12 wk after
Initiation intervention P‐value
of mesotherapy without glutathione were acceptable as well.
And also the adverse effects presented by patients including er‐
Right side 4.52 ± 1.90 1.47 ± 0.77 <0.001
ythema, edema, and ecchymosis were not significantly different
Left side 4.57 ± 1.85 2.75 ± 1.28 <0.001
compared in two groups. Comparison of two groups showed that
P‐value 0.461 <0.001
presence of glutathione used in group A (right side of the face)
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6       IRAJI et al.
was accompanied with significant better results than what was
achieved in group B (left side of the face). Another superiority of
group A remedy in comparison with group B was patients’ satis‐
faction of melasma responses to drugs that their right side of face
status within 12 weeks was more satisfying for them than left side.
Further, 12‐week follow‐up of our patients showed no recurrence.
Based on our research, this subject has been conducted for the
first time worldwide. In a study conducted by Shelly Rivas et al in
2013, they have reviewed over forty studies in this term and pre‐
sented that combination therapy was accompanied with more sig‐
nificant improvement of melasma in comparison with monotherapy
or chemical peels and laser.19
5 |  CO N C LU S I O N
Use of combination mesotherapy in treatment of melasma was ac‐
companied with appropriate outcomes regardless of type of meso‐
therapy agents but treatment with glutathione containing cocktail
A presented superior results compared with treatment of cocktail
containing tranexamic acid and vitamin C but not glutathione.
5.1 | Limitations
One of the limitations of our study was lack of assessing patients'
response to treatment and complications considering their type of
melasma (epidermal, dermal, and mixed). In this regard, further stud‐
ies are recommended.
AC K N OW L E D G M E N T
We thank all the patients who participated in this study and Arman
clinic staff.
ORCID
Mojtaba Nasimi  https://orcid.org/0000-0002-5310-8467
REFERENCES
1. Elfar N, El‐Maghraby G. Efficacy of intradermal injection of
tranexamic acid, topical silymarin and glycolic acid peeling in treat‐
ment of melasma: a comparative study. J Clin Exp Dermatol Res.
2015;6(280):2.
2. Iraji F, Tagmirriahi N, Gavidnia K. Comparison between the efficacy
of 10% zinc sulfate solution with 4% hydroquinone cream on im‐
provement of melasma. Adv Biomed Res. 2012;1(1):39.
3. Kavya M. Melasma: a clinico‐epidemiological study. Int J Basic Appl
Med Sci. 2014;4(2):388‐391.
4. Pawaskar MD, Parikh P, Markowski T, Mcmichael AJ, Feldman SR,
Balkrishnan R. Melasma and its impact on health‐related quality of
life in Hispanic women. J Dermatol Treat. 2007;18(1):5‐9.
5. Budamakuntla L, Loganathan E, Suresh DH, et al. A randomised,
open‐label, comparative study of tranexamic acid microinjections
and tranexamic acid with microneedling in patients with melasma. J
Cutan Aesthet Surg. 2013;6(3):139.
6. Ebrahimi B, Naeini FF. Topical tranexamic acid as a promising treat‐
ment for melasma. J Res Med Sci. 2014;19(8):753.
7. Lee JH, Park JG, Lim SH, et al. Localized intradermal microinjection
of tranexamic acid for treatment of melasma in Asian patients: a
preliminary clinical trial. Dermatol Surg. 2006;32(5):626‐631.
8. Tse TW, Hui E. Tranexamic acid: an important adjuvant in the treat‐
ment of melasma. J Cosmet Dermatol. 2013;12(1):57‐66.
9. Parvez S, Kang M, Chung HS, et al. Survey and mechanism
of skin depigmenting and lightening agents. Phytother Res.
2006;20(11):921‐934.
10. Arjinpathana N, Asawanonda P. Glutathione as an oral whitening
agent: a randomized, double‐blind, placebo‐controlled study. J
Dermatol Treat. 2012;23(2):97‐102.
11. Watanabe F, Hashizume E, Chan GP, Kamimura A. Skin‐whitening
and skin‐condition‐improving effects of topical oxidized glutathi‐
one: a double‐blind and placebo‐controlled clinical trial in healthy
women. Clin Cosmet Investig Dermatol. 2014;7:267.
12. Solano F, Briganti S, Picardo M, Ghanem G. Hypopigmenting
agents: an updated review on biological, chemical and clinical as‐
pects. Pigment Cell Melanoma Res. 2006;19(6):550‐571.
13. Pandya A, Berneburg M, Ortonne JP, Picardo M. Guidelines for clin‐
ical trials in melasma. Br J Dermatol. 2006;156:21‐28.
14. Pandya AG, Hynan LS, Bhore R, et al. Reliability assessment and val‐
idation of the Melasma Area and Severity Index (MASI) and a new
modified MASI scoring method. J Am Acad Dermatol. 2011;64(1):
78‐83.e1‐2.
15. Dunbar S, Posnick D, Bloom B, Elias C, Zito P, Goldberg DJ. Energy‐
based device treatment of melasma: an update and review of the
literature. J Cosmet Laser Ther. 2017;19(1):2‐12.
16. Grimes PE. (Ed.). Management of hyperpigmentation in darker ra‐
cial ethnic groups. Seminars in cutaneous medicine and surgery.
Frontline Medical Communications; 2009.
17. Espinal‐Perez LE, Moncada B, Castanedo‐Cazares JP. A double‐
blind randomized trial of 5% ascorbic acid vs. 4% hydroquinone in
melasma. Int J Dermatol. 2004;43(8):604‐607.
18. Villarama C, Maibach H. Glutathione as a depigmenting agent: an
overview. Int J Cosmet Sci. 2005;27(3):147‐153.
19. Sriharsha M, Alekhya P, Darsini TP, Reddy K. Gluthathione as a
whitening agent in the treatment of melanos is on face. J Agri Life
Sci. 2015;1(2):48‐56.
How to cite this article: Iraji F, Nasimi M, Asilian A, Faghihi
G, Mozafarpoor S, Hafezi H. Efficacy of mesotherapy with
tranexamic acid and ascorbic acid with and without
glutathione in treatment of melasma: A split face
comparative trial. J Cosmet Dermatol. 2019;00:1–6. https://
doi.org/10.1111/jocd.12874