Dermoscopy Serves Dual Role in Melasma Management

Characteristics that distinguish facial hyperpigmentation disorders 17/07/21 09.
42
Facial pigmentation impacts quality of life

regardless of clinical severity
August 7, 2020
Lisette Hilton
In a study of more than 200 men and women, clinicians scored patients’ pigmentation
taking into account how much of the face was impacted and compared scores to
patients’ responses to the Skindex-16 questionnaire.
Facial pigmentary disorders, including melasma, impact quality of life for both men and
women, but women tend to be emotionally more affected than men, according to a study
published March-April in the Indian Dermatology Online Journal.
“As face is the most visible part of the body, any blemish on it can have a serious impact
on the psychological wellbeing of the individual. Causes of facial melanosis are many
and varied and each of them can have an impact on the quality of life,” said the study’s
lead author Leena Raveendra, M.D., associate professor of dermatology at Rajarajeswari
Medical College and Hospital, in Bangalore, Karnataka, India.
Dr. Raveenra and colleagues studied 186 women and 52 men diagnosed at the hospital
in India with facial pigmentation from April 2015 to March 2016. While 73% of those
studied had melasma, the most common of the pigmentary disorders, 5.8% of patients
had post-inUammatory hyperpigmentation or photo tanning. Other diagnoses included
lichen planus pigmentosus, freckles and Nevus of Ota. Researchers noted 0.42% of
cases were diagnosed as acanthosis nigricans, Becker’s nevus, pigmentary demarcation
lines, Nevus spilus, seborrheic melanosis, or post-chikungunya pigmentation.
RELATED: How melasma differs in male patients
The clinicians scored patients’ pigmentation taking into account how much of the face
was impacted, pigmentary severity compared to normal skin, and pigmentation
uniformity, including whether it was speckled or diffuse. Patients also responded to the
Skindex-16 questionnaire, a proven instrument that measures quality of life in people
with skin diseases.
Looking at patients’ quality of life, which can give dermatologists a perspective on

patients’ feelings of joy and satisfaction, has become increasingly important in the
management of patients with skin diseases, according to the paper. That’s especially
true when it comes to facial skin disorders. The authors noted that other studies suggest
people with facial skin conditions are at risk for depression, as well as feelings of
loneliness and isolation.
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Characteristics that distinguish facial hyperpigmentation disorders 17/07/21 09.42
“Melasma has been the focus of the studies on hyperpigmentation of the face. It is
known to reduce the quality of life of the patients. Other causes of pigmentation have a
similar or sometimes more impact on the quality of life,” Dr. Raveendra said.
Dr. Raveendra and colleagues found the quality of life impact happened regardless of
pigmentation severity or how they scored facial pigmentation.
The mean pigmentation score was 20.39, with clinicians noting mild pigmentation in
41.17% of patients, compared to moderate in 42% and severe pigmentation in 16.8% of
cases.
Patients’ mean Skindex score was 1.12, with a mean emotion score of 17.32. While the
authors only noted a slightly higher mean Skindex-16 score among females in the study,
they reported a more signi^cant difference in emotion, with females scoring the
emotional impact of pigmentary disorders higher than males. Mean skin index scores
were highest for post-chikungunya pigmentation and lowest for melasma and post-
inUammatory pigmentation.
There was only a weak positive correlation between the clinicians’ pigmentation score
and Skindex-16.
“Skindex-16 score against different grades of pigmentation showed that the mean
Skindex-16 score was higher in severe cases but there was no statistically signi^cant
difference between the groups,” they wrote.
Dr. Raveendra told Dermatology Times that the extent and severity of facial pigmentation
in the study was not proportional to the severity of impairment of quality of life.
“Even a small blemish on the face can decrease the quality of life and have an impact on
their psychological wellbeing,” she said.
Disclosure:
Dr. Raveendra reports no relevant disclosures.
Reference:
Raveendra L, Sidappa H, Shree S. A Study of Quality of Life in Patients with Facial

Melanoses. Indian Dermatol Online J. 2020;11(2):154-157. Published 2020 Mar 9.
Emerging Agents Augment Melasma Modalities

April 9, 2021
Cheryl Guttman Krader, BS, Pharm
Dermatology Times, Dermatology Times, April 2021 (Vol. 42, No. 4),
An array of agents for blocking visible light and lightening skin are joining the
armamentarium to treat melasma. Despite this expanding number of therapeutic
interventions, melasma is a chronic, therapeutically challenging disease for which there
is no cure, so treatment plans should address both management of the disease and
patient expectations.
New treatment modalities and novel compounds are expanding the armamentarium for
managing melasma and preventing relapse, said Pearl E Grimes, MD, in her update on
this challenging skin disease at Maui Derm 2021.1
Grimes, a Dermatology Times®’ editorial advisory board member, is the director of The
Grimes Center for Medical and Aesthetic Dermatology, director of the Vitiligo and
Pigmentation Institute of Southern California, and clinical professor of dermatology at
the David Geffen School of Medicine at UCLA, all in Los Angeles.
Her presentation highlighted new solutions to optimize melasma management and

identiêd cautions that could negatively impact outcomes.
Approaches for Photoprotection
Photoprotection from ultraviolet light has been a long-standing element in the melasma
management algorithm. However, ^ndings from recent studies indicating that visible
light is also a trigger for the pathogenic pathway have spurred research showing the
bene^ts of photoprotection strategies using iron oxide sunscreens that block visible
light, Grimes noted.
“Using these modalities in our practice, we are seeing they have a signi^cant positive
impact in patients with melasma,” Grimes said. “Oral Polypodium leucotomos extract has
also been investigated as a novel photoprotective agent in melasma. Recent data
suggest that [it] also blocks visible light, and it has shown bene^t as an adjunctive
modality for melasma patients in several randomized studies.”
Current evidence from histological studies suggesting that melasma likely represents a
phenotype of photodamage carries implications for long-term management, Grimes
noted.
Novel Lightening Agents
In addition to photoprotection, topical lighteners have a cornerstone role in managing

melasma. Most lighteners used currently act via tyrosinase inhibition. Hydroquinone has
been the major workhorse in this category for 60 years. However, new and emerging
agents are showing substantially greater elcacy, according to Grimes.
Newer options for treating hyperpigmentation include cysteamine, methimazole,

silymarin, tranexamic acid (TA), glutathione, melatonin, and new combination
formulations. Most of these agents also inhibit tyrosinase activity, but some have
different or multimodal mechanisms of action and have been used with varying routes of
administration, Grimes said.
TA is one example. This anti^brinolytic agent suppresses angiogenesis, mast cells, and
arachidonic release. It has been used orally, topically, and intralesionally with good
results, she said. However, Grimes pointed out some concerns with TA—including an
almost-universal risk for relapse after treatment is stopped and a risk for inducing
thromboembolic phenomena.
“Although thromboembolic events are uncommon or rare in studies investigating TA for

dermatologic conditions, patients should be screened for thromboembolic risk factors,”
she advised.
Therapeutic Procedures
Procedural interventions are strategic partners in the multimodality approach for

melasma.
Chemical peels are part of the armamentarium for treating melasma as a second-line
regimen, and super^cial peels are preferred for treating melasma in darker-skinned
patients.
“Findings from a meta-analysis showed that for patients with Fitzpatrick phototypes IV
to VI, increasing the depth of the peel also increases the risk of more [adverse] effects or
deleterious outcomes,” Grimes said.
Maximizing outcomes with peels requires a combination approach, in which a topical

lightener is used for 2 to 4 weeks preceding the peel and between procedures, she said,
adding that in her opinion, the daily regimen is key to achieving best-possible results.
Grimes pointed out that multiple recent studies also show that microneedling can have a
role in melasma treatment when used in combination with a topical lightening agent. But
there are certain caveats.
“In my experience, it is essential to have patients on a daily topical lightening agent when
using microneedling. Without it, there is a signi^cant risk for development of
postinUammatory hyperpigmentation,” Grimes said.
Light-based treatments using lasers or intense pulsed light (IPL) sources may target
deeper pigmentation along with a vascular component of melasma that is much more
prominent than previously thought.
“Very tiny telangiectasia can often be seen when closely examining patches of
melasma,” said Grimes. “Although these vessels were once considered a result of what
patients had used for treatment, they are now known to be part of the melasma
spectrum.”
Only fractional 1550/1540 nm nonablative lasers are approved by the FDA for treating
melasma. However, treatment with a low-Uuence Q-switched Nd:YAG laser may be the
best option for refractory cases of melasma, according to Grimes. Excellent results can
also be achieved using IPL sources in Fitzpatrick skin types II, III, and sometimes IV, she
added.
However, because of the risk for signi^cant complications, IPL should be used with
extreme caution in darker-skinned patients. “The Q-switched ruby and erbium:YAG lasers
are best avoided completely,” she said.
Managing Expectations
Despite the expanding number of therapeutic interventions, the fact remains that
melasma is a chronic and therapeutically challenging disease for which there is no cure.
Moreover, relapses are almost universal, said Grimes. Therefore, establishing realistic
expectations for outcomes remains a critical aspect of the therapeutic consultation.
“Whereas we can cure postinUammatory hyperpigmentation of the face often caused by

acne by treating the inciting condition, it is essential to articulate to patients with
melasma that their pigmentary disorder requires long-term management,” Grimes said.
“Meanwhile, we continue to have hope that the quest to ^nd new therapies for this
psychologically devastating condition will lead to options that are more durably
elcacious.”
Disclosure:
Grimes has conducted clinical research and/or served as a consultant for Procter &
Gamble, Clinuvel Pharmaceuticals Ltd, L’Oréal, Johnson & Johnson, LaserOptek, VT
Technologies, Incyte, P^zer Inc, and DermaForce.
Reference:
1. Grimes PE. Update 2021: disorders of pigmentation. Presented at: Maui Derm Live In-
Person Dermatology CME Conference and Maui Derm Connect Virtual Dermatology CME
Conference; January 25-29, 2021; Maui, Hawaii; virtual.
Download Issue : Dermatology Times, April 2021 (Vol. 42, No. 4)
Laser-assisted delivery of tranexamic acid for

melasma
December 23, 2020
Lisette Hilton
Findings from two recent pilot studies suggest 1927 nm fractional thulium fiber laser-
assisted topical tranexamic acid delivery is a safe, effective melasma treatment option.
Findings from two recent pilot studies suggest 1927 nm fractional thulium ^ber laser-
assisted topical tranexamic acid delivery is a safe, effective melasma treatment option.
A theory of how melasma occurs suggests ultraviolet light increases plasmin activity in
keratinocytes, according to the study “Laser‐assisted delivery of tranexamic acid for
melasma: Pilot study using a novel 1927 nm fractional thulium ^ber laser,” published
Nov. 11, 2020 in the Journal of Cosmetic Dermatology.
“… which has led to the investigation of tranexamic acid for treatment melasma, since it
possesses anti-plasmin properties. The use of laser-assisted drug delivery can also
increase the uptake of topical medications,” wrote the study’s author, from the Laser &
Skin Surgery Center of New York, New York.
Clinician authors treated 10 melasma patients with ^ve full-face low-energy, low-density
1927 nm fractional thulium ^ber laser treatments. They set the LaserMD (Lutronic) laser
to Random Mode with a 4W to 5W output power, 2mJ to 8mJ Uuence and using 2 to 8
passes, according to the paper.
Immediately after laser treatment, they applied topical tranexamic acid and instructed
patients to apply the tranexamic acid topical twice daily for the next seven days.
The authors reported on patients’ clinical outcomes, quality of life and satisfaction.
Seven of the initial 10 melasma patients enrolled completed the study. All were female
and had Fitzpatrick skin types II, III and IV.
They found Melasma Area Severity Index (MASI) scores improved an average 1.1 at 30
days, 3.5 at 90 days and 2.5 points at 180 days. The average MASI score at baseline was
10.6, with the biggest improvement from treatment occurring at 90 days. Three of the
seven patients experienced melasma recurrence and a worsening of their MASI score by
day 180.
Investigators and subjects also used the 3-point Global Aesthetics Improvement Scale to
grade clinical improvement at follow ups. Investigators rated improvement from baseline
in ^ve subjects at the 30- and 90-day follow up visits and six subjects at 180 days. They
rated the others as having no clinical change. Using the Global Aesthetics Improvement
Scale, six subjects reported improvement at 30 and 90 days and seven, 100%, saw
improvement from baseline at 180 days.
Patients reported an average 9.6-point improvement on the Melasma Quality of Life

Scale at 30 days. A few patients reported other positive changes in their facial skin, from
radiance to improvements in skin texture and tone.
At 30 days, ^ve subjects were satisêd with treatment and would recommend it to their
friends and family for melasma.
Subjects experienced predictable side effects of transient roughness, dryness and

itching. All were mild and resolved without treatment.
The authors wrote that this study, which is limited by the small number of subjects,
suggests that combining low-energy, low-density 1927 nm fractional thulium ^ber laser
and tranexamic acid can improve melasma patient outcomes. But large-scale studies
with a split face design would better assess how this combination approach compares
to tranexamic monotherapy.
Authors of another paper, “The elcacy in treatment of facial melasma with thulium
1927-nm fractional laser-assisted topical tranexamic acid delivery: a split-face, double-
blind, randomized controlled pilot study,” published December 2020 in Lasers in Medical
Science, reported a strong bene^t from treating moderate to severe long-term melasma
with topical tranexamic acid assisted by the sub-ablative fractional 1927 nm thulium
laser.
In the split-face study, researchers from Thailand and the Philippines compared
fractional thulium laser alone with laser-assisted delivery of topical tranexamic acid.
Patients in the study were predominately female with a mean melasma duration of 6.9
years. They treated the 46 adults with four weekly fractional 1927 nm thulium laser
treatments on the full face, immediately followed by tranexamic acid topical treatment
on one side and saline solution on the control side.
They reported on patients using the Melanin Index, modiêd MASI and patient self-
assessment scores at baseline, weeks 1 and 3, and at 3 and 6 months after the ^nal
treatment.
They found highly signi^cant improvement from the combination maintained until 3
months.
“High signi^cance was seen in the [Melanin Index] for both sides at the 1st-month
assessment, and although very high signi^cance was maintained for [tranexamic acid] at
3 months post ^nal treatment… signi^cance decreased for the control side…,” they wrote.
There was some reversal of improvement after 3 months and to 6 months after
treatment on the tranexamic acid side, but the 6-month results from the 29 patients still
in the study continued to show signi^cant improvement from baseline in some
measures.
“These ^ndings thus support the possibility of a treatment regimen for recalcitrant
melasma patients involving 4 weekly sessions of topical [tranexamic acid] with
[fractional thulium laser], with a repeat regimen performed every 3 or 4 months,” they
wrote.
References:
1. Wang, JV, Christman, MP, Feng, H, Ferzli, G, Jeon, H, Geronemus, RG. Laser‐assisted

delivery of tranexamic acid for melasma: Pilot study using a novel 1927 nm fractional
thulium ^ber laser. J Cosmet Dermatol. 2020; 00: 1–
5. https://doi.org/10.1111/jocd.13817
2. Wanitphakdeedecha, R., Sy-Alvarado, F., Patthamalai, P. et al. The elcacy in treatment

of facial melasma with thulium 1927-nm fractional laser-assisted topical tranexamic
acid delivery: a split-face, double-blind, randomized controlled pilot study. Lasers Med
Sci 35, 2015–2021 (2020). https://doi.org/10.1007/s10103-020-03045-8
Disclosures: Lutronic funded and supported the study in the Journal of Cosmetic
Dermatology and provided the topical products used in it. No conUicts reported in the
Lasers in Medical Science paper.
Targeting melasma’s vascular component

improves treatment outcomes, prevent relapse
December 18, 2020
Lisette Hilton
Dermatologists should consider assessing melasma patients for increased vascularity

and include antivascular treatments to improve outcomes among patients whose lesions
have a vascular component.
Dermatologists should consider assessing melasma patients for increased vascularity

and include antivascular treatments, including tranexamic acid and laser and light
therapies, to improve outcomes among melasma patients whose lesions have a
vascular component.
“Methods of evaluation of the vascular component of melasma are relatively accessible

and may positively impact the patient’s clinical course, particularly for recalcitrant
melasma cases,” researchers from the Department of Dermatology at State University of
New York reported in their study “The Vascular Component of Melasma: A Systematic
Review of Laboratory, Diagnostic, and Therapeutic Evidence,” published Dec. 2020 in
Dermatologic Surgery.
In a systematic review of 34 published research articles, the authors found strong

evidence for what they called “the important and underreported vascular component of
melasma.”
Melasma treatment remains challenging despite conventional melasma treatment

regimens focused on sun protection and lightening agents. Genomics, hormonal
imbalance and UV exposure are widely accepted contributors to melasma pathogenesis.
But evidence is building that suggests there may be an important vascular component to
melasma pathogenesis, according to the paper.
“Emerging evidence indicates that melasma pathogenesis may involve aberrant

angiogenesis and vasodilation of dermal blood vessels, rather than solely increased
melanogenesis resulting in hyperpigmentation,” the authors wrote.
The authors hypothesize that increased vasculature, vasodilation and inUammation

result dermal capillaries in melasma lesions becoming increasingly permeable. The
capillaries leak red blood cells, which contributes to hyperpigmentation that might come
from solar light or light from electronic devices.
The evidence
Histological evaluations and studies looking at proangiogenic and vascular marker

expressions seem to support that melasma has a vascular component. Included among
those are several studies looking at melasma biopsy samples, which show melasma
lesions have increased vascularity compared to normal skin.
Authors of a diagnostic study found vascular endothelial growth factor (VEGF) is

upregulated in melasma but did not ^nd that VEGF was related to melanin synthesis,
melanocyte proliferation or melanocyte migration.
Researchers have also reported an overexpression of inducible nitric oxide synthase

(iNOS), a vasodilation mediator, is featured in melasma lesions. Adding to the evidence,
researchers have found endothelial cells play an important role in physiologic
pigmentation, but more research is needed to characterize that role in melasma,
according to the paper.
Studies looking at clinical evidence of vascular characteristics in melasma have found

visibly increased vascularity in melasma lesions, including distinct telangiectatic
erythema.
Researchers have used dermoscopy in diagnostic studies to reveal melasma

hypervascularity. Those vascular features improved with treatment, according to the
paper.
“Patients with visibly widened capillaries on dermoscopy showed greater improvements

in the Melasma Area and Severity Index (MASI) score after several antivascular
treatments, including tranexamic acid (TXA) and combination Q-switched Nd:YAG (QS
Nd:YAG) laser and pulsed dye laser (PDL), compared with patients without these
dermoscopic features,” they wrote.
Which antivascular treatments appear to work?
The authors reviewed ^ve studies, including case reports, on outcomes using the 595nm
pulsed dye laser to treat melasma. Researchers have found that pulsed dye laser
treatment, which destroys blood vessels by targeting the chromophore oxyhemoglobin,
improves melasma’s vascularity.
Combinations seem to work well. In a split-face study, daily treatment with the pulsed
dye laser along with triple combination therapy with hydroquinone, tretinoin and
Uuocinolone led to a signi^cant and sustained decrease in the MASI score. In one
patient who presented three years later with a melasma relapse, the lesions were not in
the previously treated areas.
Authors of a retrospective review studied the elcacy of melasma treatment combining

pulsed dye laser with a 1927 nm low-power fractional diode laser and found 54% of
patients had great than 50% improvement in the presentation of their melasma
compared to baseline.
Even the 1064 nm Q-switched Nd:YAG laser was clinically effective as a melasma
treatment in three studies. But researchers looking at melasma treatment with the
copper bromide laser have reported conUicting results, according to the paper.
The authors pointed out that pulsed dye laser, Q-switched Nd:YAG and other light
therapies can result in post-inUammatory hyperpigmentation and other adverse events,
particularly in patients with darker skin types.
Researchers have reported improvements in melasma after treatment with the

pharmacologic therapy tranexamic acid, whether given orally or topically. In one study,
patients with vascular dermoscopic features had greater improvement after applying a
tranexamic acid topical for 8 weeks than those who applied a cream without tranexamic
acid. In vitro research suggests tranexamic acid decreases expression of several VEGF
receptors in endothelial cells and melanocytes, as well as decreases melanocyte
proliferation, melanin content, and melanogenic protein expression, according to the
authors. Other research suggests tranexamic acid might decrease melasma
vascularization by vasoconstriction.
What should dermatologist to do?
Melasma remains a therapeutic challenge, and dermatologists have easy access to

ways in which they can assess and treat a possible vascular component to improve
outcomes.
In addition to physical examination for evaluating melasma lesion vascularity,

dermatologists might use dermoscopy, colorimetry and reUectance confocal
microscopy.
“After evaluation of vascularity, dermatologists may then consider adding targeted

antivascular therapy to the patient’s treatment regimen,” they wrote.
While the therapeutic options include laser and light therapies and tranexamic acid, the
authors recommended that dermatologists use an antivascular therapeutic based on
patient preference, treatment goals and therapeutic availability. Dermatologists should
weigh treatment bene^ts with risks, they wrote.
Future research on the topic should include randomized controlled trials, larger sample
sizes, longer follow up and standardized evaluation methods, according to the paper.
Reference:
1 Masub N, Nguyen JK, Austin E, Jagdeo J. The Vascular Component of Melasma: A

Systematic Review of Laboratory, Diagnostic, and Therapeutic Evidence. Dermatol Surg.
2020 Dec;46(12):1642-1650. doi: 10.1097/DSS.0000000000002770. PMID: 33252894.
Disclosures: None reported.
Cysteamine cream, tranexamic acid mesotherapy

reveal similar efficacy, different safety
October 14, 2020

Lisette Hilton
Cysteamine cream and tranexamic acid mesotherapy demonstrated similar efficacy but
yielded different safety results when being compared as a treatment for melasma,
according to a recently published study.
Researchers comparing melasma treatment cysteamine 5% cream to tranexamic acid

mesotherapy found both were similarly effective but cysteamine cream appears to be
safer.
The single-blind, randomized study of 54 Iranian patients with melasma was published
Sept. 2 in the Archives of Dermatological Research.
Melasma treatment involves reducing melanocyte proliferation and inhibiting

melanosome formation.“[Tranexamic acid] inhibits plasmin activity by preventing the
adhesion of plasminogen to keratinocyte resulting in reduced prostaglandin and
ultimately decreased melanocyte tyrosine kinase activity,” the authors wrote.
The simplest aminothiol in cells, cysteamine, has antioxidant properties and has long
been shown in studies as a potent depigmenting molecule, according to the paper.
Researchers compared the treatments in a study of predominately female patients

presenting to an Iranian dermatology clinic between November 2018 and July 2019.
Those included in the study had suffered from melasma for at least a year and had not
treated the condition with medication for at least two months.1
Over the course of four months, participants randomly received cysteamine 5% cream,
which they were told to apply to melasma lesions after washing and drying their faces
30 minutes before bedtime.
Dermatologists performed mesotherapy on patients randomized to the other group

using intradermal microinjections tranexamic acid mesotherapy, 0.05 mL (4 mg/mL).
They delivered the injections using a 28-gauge needle at a depth of 1 mm with 10 mm
distance to three areas. Dermatologists treated patients in the tranexamic acid group
every four weeks, up to two months.1
To assess healing, the authors used the Dermacatch device (Colorix), which uses
reUective light to measure melanin and erythema, and the modiêd Melasma Area
Severity Index (mMASI).
Most of the patients studied, 29, had moderate melasma at baseline, with 12 being
considered mild and 13 severe.1
They found melasma lesions improved by a rate of 32.5% at the second visit and 48% at
the third visit in the tranexamic acid group. These rates were not signi^cantly different in
the cysteamine group, according to the study.1
“The most remarkable improvement rate was observed in the [tranexamic acid] group at
the third visit based on mMASI and Dermacatch values at 47% and 15% in turn,” they
wrote.
Dermacatch values fell, signaling improvement, at the second and third visits similarly in
both groups.
Complications, however, differed between groups with cysteamine appearing safer than
tranexamic acid mesotherapy. Researchers found tranexamic acid patients were
signi^cantly more likely to have treatment-related erythema, itching, burning and
irritation compared to those treated with cysteamine. For example, among patients in
the cysteamine group, 20 experienced no erythema, ^ve had mild erythema, two had
moderate and none of the patients in the group had severe erythema. Conversely, none
of the patients in the tranexamic group were free of erythema. Twenty had mild, four
moderate and three severe erythema as a result of treatment.
Most patients, 20, treated with cysteamine reported no itching, compared to 21 patients
who reported mild itching in the tranexamic acid group. There was no notable difference
in dryness between the groups.
“Overall, patients in the cysteamine group were in the none or mild categories of
complications as compared to the [tranexamic acid] mesotherapy group,” they wrote. “It
is worth noting that no recurrences of melasma were witnessed during the four months
and eight weeks’ follow-up period for cysteamine and [the tranexamic acid] group,
respectively.”
It is good to have options that show elcacy in melasma treatment because often used
tyrosinase inhibitors, such as hydroquinone, azelaic acid and arbutin, result in common
side effects from photosensitivity to pruritus and scaling, according to the authors.
Larger, carefully designed studies looking at determining optimal dosage, application

frequency, bene^ts and sustained effects from these treatments should follow.
Researchers should also conduct similar studies with longer follow ups to determine
rate of relapse or tapering, they wrote.
Melasma prevalence in Arab-American populations is 13.4 to 15.5%, according to a

study published July-August in the Pakistan Journal of Medical Sciences.2
These researchers compared the elcacy of tranexamic acid mesotherapy to 0.9%

normal saline for melasma in a split-face study. The 12-week study suggests hemi-
modiêd Melasma Area and Severity Scoring (H-mMASI) was signi^cantly reduced from
an average 3.19 to 1.52 on the tranexamic side compared to a decline in scores on
placebo side.2
“Tranexamic Acid … mesotherapy can be considered as the most cost-effective, safe and
directly observed therapy for melasma which showed signi^cant improvement when old
prior therapies have failed,” they concluded.
Reference:
1. Karrabi, M., Mansournia, M.A., Sharestanaki, E. et al. Clinical evaluation of elcacy and
tolerability of cysteamine 5% cream in comparison with tranexamic acid mesotherapy in
subjects with melasma: a single-blind, randomized clinical trial study. Arch Dermatol
Res (2020). https://doi.org/10.1007/s00403-020-02133-7
2. Kaleem S, Ghafoor R, Khan S. Comparison of elcacy of Tranexamic Acid

Mesotherapy versus 0.9% normal Saline for Melasma; A split face study in a Tertiary
Care Hospital of Karachi. Pak J Med Sci. 2020;36(5):930-934.
doi: https://doi.org/10.12669/pjms.36.5.2379
Disclosure: None declared in the paper.
730 nm picosecond laser safe, effective for

benign pigmented lesions
October 14, 2020
Lisette Hilton
Lasers typically used for tattoo removal are on the rise as a possible treatment for
melasma, with the novel 730 nm picosecond laser (PicoWay, Candela) being the most
recently studied device which showed to be safe and effective for treating benign
pigmented lesions.
A laser typically used for tattoo removal appears to be a safe and effective option for
treating benign pigmented lesions, according to a study published Sept. 1 in Lasers in
Surgery and Medicine.
In a study of 22 patients, researchers found treating benign pigmented lesions with the
novel 730 nm picosecond titanium sapphire laser (PicoWay, Candela) was promising.
“This is the ^rst study analyzing the safety and elcacy of a novel 730 nm 250
[picosecond] titanium sapphire laser for the treatment of benign pigmented lesions,” the
authors wrote. “The data demonstrates that this laser has the potential to deliver
signi^cant cosmetic bene^t in treating discrete pigmented lesions, is well-tolerated and
can achieve signi^cant results in a small number of treatment sessions.”
Dermatologists in California did a retrospective review of patients presenting from

December 2019 to March 2020 at a single institution with benign pigmented lesions for
treatment with the 730 nm picosecond laser. The 22 patients, of all Fitzpatrick skin
types, had not been treated in the previous three months with a pigment-speci^c laser.
The authors treated patients with a 730 nm picosecond titanium sapphire laser, which is
a separate handpiece that clinicians can attach to the base of an Nd:Yag laser platform.
The device has a maximum energy of 100 mJ, 250 second pulse duration, spot sizes
from 2 to 4 mm, 1 to 10 Hz repetition rates and adjustable Uuence, according to the
paper.1
Two blinded dermatologists did absolute and relative evaluations of patients between
weeks four and eight.
Dermatologists diagnosed nearly 70% of the patients with melasma. Patients had an
average of 1.1 treatments and average follow up of 36 days.1
They used a four-point scale, with zero being no pigment; one, light pigment; two,
medium pigment; and four being dark pigment. Patients’ average pigmentation score
was 2.04 at baseline versus 1.39 post treatment. Before and after images showed 86%
of patients’ pigmentation improved.1
However, 3% of patients had no improvement and 11% had worse pigmentation, with
post-inUammatory hyperpigmentation following treatment.1
In a sub-analysis of improvement scores, they found 76% of patients improved 30% or

more; 60% improved 50% or more; and 31% improved 70% or more.1
Patients graded treatment related pain as minimal to none. All were treated with a
topical numbing cream. Most healed within a day or two, followed by three to ^ve days
of mild pigment darkening and crusting.
Authors of other studies have shown that picosecond lasers at 532nm, 755 nm, 785nm
and 1064 nm safely and effectively treat discrete pigmented lesions, from solar
lentigines and freckles to Becker’s nevi and more. While nanosecond lasers have been
linked in studies to substantial post inUammatory hyperpigmentation risk from 25% to
47%, post inUammatory hyperpigmentation rates with the picosecond laser in studies
have been between 5% and 10%. The authors of this study wrote that the slightly higher
post inUammatory hyperpigmentation rate of 11% could be natural variation, or perhaps
because two of the patients studied had skin types V and VI.1
“Within the population of patients who developed [post inUammatory hyperpigmentation]

the rate of underlying melasma was 83%,” they wrote.
Dermatologists use picosecond lasers mostly for tattoo removal, followed by removal of
benign pigmented lesions. Researchers recently studied the speci^c picosecond laser in
this study for tattoo removal, but the technology is otherwise new, according to the
paper.
“Future prospective randomized control studies would be bene^cial to further clarify its
role in the treatment of benign pigmentation,” the authors wrote.
Reference:
1. Lipp, M.B., Angra, K. and Wu, D.C. (2020), Safety and Elcacy of a Novel 730 nm
Picosecond Titanium Sapphire Laser for the Treatment of Benign Pigmented Lesions.
Lasers Surg Med. doi:10.1002/lsm.23314
Disclosure: The study’s senior author Douglas C. Wu, M.D., Ph.D., reports ties to Candela,
including non^nancial support during the study.
Sunscreen demonstrates strong therapeutic

properties in patients with pigmentary disorders
September 2, 2020
Lisette Hilton
The importance of blocking visible light in the treatment of pigmentary disorders is

becoming clearer. One expert says photoprotection in patients with pigmentary
conditions is a therapeutic cornerstone.
Dermatologists have long recommended sunscreens to prevent worsening of

pigmentary disorders. But there’s mounting evidence that suggests sunscreen also has a
therapeutic role in the treatment of melasma, post-inUammatory hyperpigmentation and
chronic UV-induced hyperpigmentation, according to Susan C. Taylor, M.D., FAAD, who
presented on the topic during the American Academy of Dermatology VMX 2020.1
The evidence
The role that sunscreen plays in melasma treatment isn’t new. Dr. Taylor referred to a
study published in Cutis in 1983 in which researchers studied 53 melasma patients.2 All
patients in the double-blind study received 4% hydroquinone, the gold standard melasma
treatment, according to Dr. Taylor.
“One group received a broad-spectrum sunscreen and the other placebo. And we can
see a signi^cant difference in improvement of the melasma. We ^nd that in the group
that used the 4% hydroquinone as well as the broad-spectrum sunscreen, 96% improved,
and this is in comparison to 80% who were in the placebo group who did not use
sunscreen but only 4% hydroquinone. This con^rms the positive role of sun protection in
the treatment of melasma,” she says.
A more recent paper, published in 2019 in the Indian Journal of Dermatology,

Venereology and Leprology looked at the impact of sunscreen on post-inUammatory
hyperpigmentation and lentigines in 230 subjects.3
“The design of this particular trial is rather interesting in that all of the subjects were
required to have sun exposure for two to four hours a day during the highest intensity of
sunlight between 12 p.m. and 3 p.m.,” Dr. Taylor says. “Both groups used sunscreen
twice a day for a 12-week period of time. But here’s the difference: Group A used an SPF
50 sunscreen with UVA protection and group B used SPF 19 again with equivalent UVA
protection. They found there was equal improvement in the density of the pigmented
spots and radiance of the skin in both groups.”
The study demonstrates the value of UVA radiation protection and suggests UVB
protection isn’t as critical for improving post-inUammatory hyperpigmentation and
lentigines, according to Dr. Taylor.
Authors of another study published in 2016 in Dermatologic Surgery of 32 subjects with

photoaging who applied an SPF 30 sunscreen for a year found improvements in mottled
and discrete pigmentation, as well as evenness in skin tone.4
Beyond UVA protection, the importance of blocking visible light in the treatment of
pigmentary disorders is becoming clearer, according to Dr. Taylor. In a study of 10
subjects with skin types IV, V and VI whose backs were irradiated with either visible light
alone or a combination of visible light and UVA1, researchers found the pigmentation
induced by visible light was darker and more sustained than in the UVA1 group.5
“We’ve learned that it’s the shorter wavelengths of visible light—in the blue-violet range,
that’s about 415 nm that induces signi^cantly more hyperpigmentation as compared to
the longer visible light wavelengths in the red-light spectrum, which is about 630 nm,” Dr.
Taylor says.
Another lesson learned: visible blue light stimulates opsin-3, according to research
published 2017 in the Journal of Investigative Dermatology.6
“This activates melanogenesis-associated transcription factor and other melanogenic

enzymes, speci^cally tyrosinase and dopachrome, which form a protein complex
primarily in the melanocytes of individuals with darker skin, which produces quite
signi^cant amounts of melanin. So, we need to start to think about our photoprotection
encompassing visible light,” she says.
What blocks visible light? Iron oxide, made up of inorganic pigments that produce
optically opaque sunscreen formulations, absorbs visible light and some ultraviolet
wavelengths.
Dr. Taylor cited a study that demonstrates sunscreens that protect the skin from visible
light in addition to UVA and UVB showed better effectiveness in melasma treatment and
relapse compared to sunscreens that only protect against UVA and UVB.7 In that study
of 61 melasma subjects, all received treatment with 4% hydroquinone and applied a
broad-spectrum SPF 50 sunscreen.
“But here’s the difference. One arm of the study received the sunscreen that contained
the visible light blocker iron oxide included and the other had no visible light blocker,” Dr.
Taylor says. “What was demonstrated was that in eight weeks, the group with the visible
light blocker had 77% improvement in the [Melasma Activity and Severity Index] MASI
score compared to only 61% improvement in the group that did not have a visible light
blocker (the UV-only blocker). I think this is pretty compelling.”
Researchers have found that a concentration of 2% iron oxide in sunscreens or

foundations is needed to block the pigment enhancing effects of high-energy visible
light.
Antioxidants, commonly added to sunscreens, also help to treat pigmentary disorders. In

a study of 44 subjects who applied sunscreen containing spirulina and dimethylmethoxy
chromanol twice a day for three months, researchers found the antioxidant
supplementation signi^cantly improved sun-induced skin damage.8
“There’s another antioxidant … Licochalcone A. It’s extracted from the root of the
Glycyrrhiza inflate plant. It has been demonstrated to help block visible light and hence
the generation of increased pigmentation and the mechanism has been worked out for
Licochalcone A.9 So, this is another ingredient and antioxidant combined with sunscreen
that can be effective for melasma, as well as for post-inUammatory hyperpigmentation,”
Dr. Taylor says.
A logical next question among dermatologists is whether infrared radiation might also
impact pigmentation and pigmentary disorders. Dr. Taylor doesn’t believe it does but
pointed to the development of a new polymer coating that has been applied to zinc oxide
and titanium dioxide particles.
“This polymer coating in a series of in vitro and ex vivo studies demonstrated the ability
of mineral-based product formulations with the coating to provide protections against
UV in the 290 to 440 nm range, as well as visible light, infrared radiation and
environmental pollution, 10” Dr. Taylor says. “So, it’s something to keep in mind.”
Dr. Taylor concluded that photoprotection in patients with pigmentary conditions is a

therapeutic cornerstone. For their patients with pigmentary disorders, dermatologists
should consider recommending not only sunscreens that protect against UVA and UVB,
but also visible light.
Disclosures:
Dr. Taylor is an advisory board member and speaker for Beiersdorf, Johnson and
Johnson, as well as is an or investigator for Aclaris, Allergan, Amirall, Avon, Cann Tec,
Croma Pharma, Galderma, Eli Lilly, L’Oreal, Ortho Dermatologic, P^zer, Walgreens Boots.
References:
1 Taylor S. The Future of Photoprotection for Pigmentary Disorders. Presented at:

American Academy of Dermatology VMX 2020, June 12-14, 2020.
https://www.aad.org/member/meetings-education/aadvmx
2 Vázquez M, Sánchez JL. The elcacy of a broad-spectrum sunscreen in the treatment

of melasma. Cutis. 1983;32(1):92-96.
3 Sarkar R, Garg VK, Jain A, et al. A randomized study to evaluate the elcacy and
effectiveness of two sunscreen formulations on Indian skin types IV and V with
pigmentation irregularities. Indian J Dermatol Venereol Leprol. 2019;85(2):160-168.
4 Randhawa M, Wang S, Leyden JJ, Cula GO, Pagnoni A, Southall MD. Daily Use of a
Facial Broad Spectrum Sunscreen Over One-Year Signi^cantly Improves Clinical
Evaluation of Photoaging. Dermatol Surg. 2016;42(12):1354-1361.
5 Kohli I, Chaowattanapanit S, Mohammad TF, et al. Synergistic effects of long-

wavelength ultraviolet A1 and visible light on pigmentation and erythema. Br J Dermatol.
2018;178(5):1173-1180.
6 Regazzetti C, Sormani L, Debayle D, et al. Melanocytes Sense Blue Light and Regulate
Pigmentation through Opsin-3. J Invest Dermatol. 2018;138(1):171-178.
7 Castanedo-cazares JP, Hernandez-blanco D, Carlos-ortega B, Fuentes-ahumada C,

Torres-Álvarez B. Near-visible light and UV photoprotection in the treatment of melasma:
a double-blind randomized trial. Photodermatol Photoimmunol Photomed.
2014;30(1):35-42.
8 Souza C, Campos PMBGM. Development and photoprotective effect of a sunscreen

containing the antioxidants Spirulina and dimethylmethoxy chromanol on sun-induced
skin damage. Eur J Pharm Sci. 2017;104:52-64.
9 Mann T, Eggers K, Rippke F, et al. High-energy visible light at ambient doses and
intensities induces oxidative stress of skin-Protective effects of the antioxidant and Nrf2
inducer Licochalcone A in vitro and in vivo. Photodermatol Photoimmunol Photomed.
2020;36(2):135-144.
10 Bernstein EF, Sarkas HW, Boland P, Bouche D. Beyond sun protection factor: An
approach to environmental protection with novel mineral coatings in a vehicle containing
a blend of skincare ingredients. J Cosmet Dermatol. 2020;19(2):407-415.
Characteristics that distinguish facial

hyperpigmentation disorders
September 1, 2020
Lisette Hilton
Effective treatment first requires accurate diagnosis, one expert says. He offers tips to
distinguish melasma from other disorders and suggests some patients may need to be
checked for diabetes and metabolic syndrome if they exhibit certain presentations.
By recognizing nuances in facial pigmentation, dermatologists can better diagnose and

treat patients with facial hyperpigmentation, according to Amit G. Pandya, M.D., staff
dermatologist at the Palo Alto Medical Foundation in Sunnyvale, Calif., and clinical
professor of dermatology at University of Texas Southwestern Medical Center, Dallas.
Facial hyperpigmentation is common. And dermatologists will likely encounter patients

with many of the more common facial pigmentation disorders, including lentigines,
melasma, periorbital dark circles, drug-induced hyperpigmentation, acanthosis nigricans,
lichen planus pigmentosus and maturational hyperpigmentation.
“… the ^rst thing we have to do as dermatologists is determine the cause of this

problem,” says Dr. Pandya, who presented “Unmasking Facial Hyperpigmentation,” during
the American Academy of Dermatology VMX 2020.1
Distribution, presentation
Pigmentary distribution often helps dermatologists distinguish melasma, one of the

most common of the disorders, from others.
Dr. Pandya pointed to these clues:
Melasma tends to involve the central area of the forehead; whereas, lichen planus
pigmentosus is more likely the diagnosis when lateral areas of the forehead are
involved.
“Melasma often occurs in the area above the eyebrow or under the eyebrow. However, it
does not cross the superior orbital rim and does not go above the inferior orbital rim.
That presentation is simply called dark circles around the eyes,” he said during the
presentation. “Melasma does commonly go over the bridge of the nose, but it does not
affect the tip of the nose. If it’s on the tip of the nose, that’s often seen with sarcoidosis
and drug-induced hyperpigmentation.”
Whereas patients with melasma might have pigmentary changes on the zygomatic
prominence, patients with acanthosis nigricans more likely have hyperpigmentation on
the concave area below the zygomatic prominence.
Melasma tends to occur above the mandible, versus poikiloderma of Civatte, which
occurs below the mandible.
And while the nasolabial fold usually is spared in melasma, it isn’t in seborrheic
dermatitis or drug-induced hyperpigmentation.
Lentigines, often presenting as asymmetrical, well-circumscribed hyperpigmented

macules, are more common in Asians, according to Dr. Pandya.
“… they tend to be not as symmetrical as melasma and scattered in various sun-exposed

areas of the face areas,” he said.
Hyperpigmentation that’s somewhat bluish and which can extend, below the jawline,
could be drug-induced hyperpigmentation, as in a case of minocycline pigmentation that
Dr. Pandya illustrated. Another patient with hyperpigmentation below the jawline, on the
tip of the nose, the nasolabial folds and the eyelids, which are not typical locations for
melasma, had drug-induced hyperpigmentation from a nonsteroidal anti-inUammatory
drug.
A patient presenting with hyperpigmentation strictly around the eyes and not on the
cheeks may have dark circles around the eyes, which is usually due to increased
epidermal and dermal melanin, he says.
Dr. Pandya presented a case in which the patient had hyperpigmentation of the temples,
as well as a straight line going over his zygomatic prominence. The straight line is
known as pigmentary demarcation line F, whereas the pigmentation of the temples is
due to acanthosis nigricans. Some call it maturational hyperpigmentation, according to

Dr. Pandya.
Dermatologists should consider checking some of these patients for diabetes and
metabolic syndrome, he says. He referred to a study of 123 patients with acanthosis
nigricans compared to sex- and age-matched controls.2
“The mean age of onset was 31 years. There was elevated insulin in 37%. It was
associated with male gender, positive glucose tolerance test, increased waist-hip ratio
and increased body mass index,” he says. “When you see patients with this greyish
hyperpigmentation going up the temple and in the area under the zygoma, it may be
worthwhile asking about risk factors for diabetes and metabolic syndrome, perhaps
even checking some laboratory tests. We still don’t have very data to see if this all goes
away with weight loss and control of these disorders.”
Pigmentary demarcation lines that coalesce with dark circles around the eyes is
common in the South Asian population, according to Dr. Pandya.
“You have to be able to distinguish between [demarcation lines] and melasma and other
disorders. Unfortunately, pigmentary demarcation lines are genetically determined so
these patients tend to have them throughout their lifetime. They are dilcult to treat and
they get worse during the summer,” he said.
Examining patients is an important part of diagnosing facial pigmentary disorders.

History-taking and, sometimes, other testing helps to determine the exact diagnosis, he
said.
“Effective treatment ^rst requires a correct diagnosis,” according to Dr. Pandya.
Disclosures:
Dr. Pandya is a consultant for Incyte, P^zer, Viela Bio, Villaris; and investigator for Incyte,
P^zer and Immune Tolerance Network; and has stock options with Clarify Medical and
Tara Medical Devices.
References:
1 Pandya, A. Unmasking facial hyperpigmentation. Presented at American Academy of

Dermatology Virtual Meeting Experience 2020, June 12-14, 2020.
https://aad.wistia.com/medias/7wdsnkwpka
2 Panda S, Das A, Lahiri K, et al. Facial Acanthosis Nigricans: A Morphological Marker of

Metabolic Syndrome. Indian J Dermatol. 2017;62(6):591-597.
Herbal cream as effective as hydroquinone for

melasma
August 6, 2020
Lisette Hilton
Researchers examined a group of adult women diagnosed with melasma who applied a
traditional medicinal product on one side of their face and 4% hydroquinone on the other
side.
Facial melasma patients had about the same treatment outcomes whether they applied
an herbal cream combining Cicer arietinum L. and Cucumis melo seeds or topical 4%
hydroquinone, according to a research paper published in the Journal of Herbal
Medicine.
Topical hydroquinone is a proven melasma treatment, but dermatologists often seek

alternatives to hydroquinone because of the synthetic drug’s side effect pro^le, which
includes post-inUammatory pigmentation. Another reason for the interest in herbal
treatments for melasma is that melasma can be costly to treat and herbal remedies tend
to be less expensive.
RELATED: New treatment approaches in melasma
RELATED: Antioxidant shows promise for melasma
In this paper, Iranian researchers studied a combination of active ingredients that hadn’t
been studied before in the treatment of melasma.
“The herbal medicine intervention used in this trial was a traditional medicinal product
made up of a combination of extracts of C. aritinum L. (Leguminoceae; chickpea) and C.
melo var. inodorus H.Jacq (Cucurbitaceae; melon seed). The product named Phytolight,
is manufactured by a pharmaceutical expert in the laboratory of the Pharmacological
Research Center of Medicinal Plants, Mashhad University of Medical Sciences,
Mashhad, Iran,” they wrote.
The ingredients for making the cream were purchased from a local market, they wrote.
“The level of total phenolic compounds in the extract mixture of [Cicer arietinum L.] and
[Cucumis melo seeds] was 16 mg gallic acid equivalent per gram of the extract mixture,”
according to the paper.
Researchers analyzed results from 32 adult females diagnosed with melasma. They
instructed the women to apply hydroquinone 4%, using 0.5 ^ngertip unit, on one side of
the face and the prepared combined product, using 0.5 ^ngertip unit, on the other side,
each night for 12 weeks.
Researchers evaluated patients every four weeks by digital photography, and melasma
and severity index (MASI) scores. The study, the authors explained, is triple blinded
because the investigatory, patients and analyzer were blinded regarding treatment
allocation.
They found both creams resulted in signi^cant improvement in melasma. Patients’ MASI
scores signi^cantly improved regardless of the topical used. While the difference
between the topicals was insigni^cant, there was a slight difference in favor or
hydroquinone. The MASI score decreased from 24.59 at baseline to 5 at week 12 with
hydroquinone treatment, versus from 24.84 at baseline to 7 at week 12 with the herbal
combination cream.
Interestingly, both topicals had a steady effect, without recurrence at four weeks post-
treatment, they reported.
Erythema was the most common side effect, occurring only with hydroquinone. Acne
occurred in 3.1% of patients with both treatments; erythema, dryness and scaling
occurred only with hydroquinone in 3.1% of cases.
Just over 50% of patients reported they were completely satisêd with the hydroquinone
cream, versus a slightly higher 52.3% with the herbal combination cream. Ninety percent
of patients were satisêd with results when researchers combined moderately and
completely satisêd patients.
Based on their work, the researchers concluded the herbal combination product with C.
arietinum L. and C. melo seed is an acceptable hydroquinone substitute for melasma
treatment. But the small sample size is a study limitation, and more research should be
done to con^rm these results, according to the paper.
Disclosures: Mashhad University of Medical Sciences’ research committee funded the

project. The authors reported no conUicts.
Reference:
Mahjour M, Banihashemi M, Rakhshandeh H et al. A triple-blind, randomized trial of a

traditional compound as compared to 4% hydroquinone in melasma. J. Herb Med. 2020
Feb. 19; 100308.
Dermoscopy serves dual role in melasma

management
July 1, 2020
Lisette Hilton
In patients with melasma, an in vivo imaging technique can effectively diagnose the
condition as well as measure response to laser treatment, a recent study indicates.
Dermoscopy not only effectively diagnoses melasma but also ascertains the elcacy of
low-Uuence 1064 nm Q-switched Nd:YAG laser therapy used to treat it, according to a
study published May 20 in Dermatologic Therapy.1
The fact that it can do both provides dermoscopy a clinical edge over using the modiêd
melasma area and severity index (mMASI) and colorimetry, according to the paper.
“mMASI, colorimetry and dermoscopy had ascertained the elcacy of low-Uuence 1064
[Q-switched] Nd:YAG laser in melasma; however, dermoscopy is superior to other
assessments as it can help in the diagnosis of melasma besides the follow-up
assessment and can precisely detect the detailed changes in response to treatment,” the
authors write.
Studies have shown that dermoscopy can determine melasma’s depth, differentiate
melasma from other facial pigmentation causes, monitor treatment outcomes and
detect early treatment-related complications.
RELATED: When to consider laser treatment for melasma
Today’s go-to melasma treatments range from regimens combining photoprotection,

trigger avoidance and topically applied agents to laser and light source therapies. Laser
toning with the low-Uuence 1064 nm Q-switched Nd:YAG has been shown to effectively
and safely treat melasma, although some studies suggest laser treatment might result in
hypo-melanosis or rebound hyperpigmentation.
Korean authors of a paper published in 2018 in the Journal of Cosmetic Dermatology

reported that the low-Uuence 1064-nm Q-switched Nd:YAG was the gold standard of
melasma treatment in Asia.2 Their study on 40 melasma patients showed the laser
treatment was generally safe and effective, but two patients showed mottled
hypopigmentation and rebound hyperpigmentation.
For this new study, dermatology researchers in Cairo, Egypt, analyzed dermoscopy’s
roles in assessing melasma and monitoring treatment response post-Nd:YAG.
They studied 31 mostly female patients, who were 25 to 54 years old. The patients had a
range of facial melasma distribution patterns and had melasma for 12 months to as
long as 210 months. Patients hadn’t treated their melasma for at least three months
prior to the study.
Researchers examined patients for the type and distribution of melasma. They treated
patients with the 1064 nm Q-switched Nd:YAG laser at a Uuence of 2 J/cm2, 8 mm spot
size and 3 Hz frequency. They did three to four passes with the laser until the
development of erythema but not petechiae.
Each patient had ^ve laser sessions on affected areas at two-week intervals.
Researchers evaluated patients at baseline and two weeks after the ^nal laser session,
or at the 10th week. They compared mMASI sore, a subjective melasma assessment
method looking at melasma involvement area and darkness; dermoscopic score of
pigmentary and vascular melasma elements; and colorimetric evaluation placing the
colorimeter perpendicular to the skin with minimum pressure.
They reported:
mMASI scores improved signi^cantly post-laser treatment, from 2.40 to 13.60

at baseline to 0.60 to 10.30 after treatment.
Dermoscopic scores of pigmentary and vascular elements in melasma
improved signi^cantly from three to 11 at baseline to two to eight post-1064
nm Q-switched Nd:YAG treatment.
Patients’ globular and perifollicular patterns improved signi^cantly post-
treatment.
Colorimetric evaluation yielded melanin indices from 565 to 761 and erythema
indices from 428 to 471 before treatment compared to melanin indices from
558 to 675 and erythema indices of 415 to 459 after laser treatment.
There were no correlations noted among the three scores.
Transient mild erythema was the only treatment-related side effect reported.
Patient satisfaction scores revealed excellent improvement in seven patients;
good improvement in 11; moderate improvement in 10; and poor improvement
in 3 patients.
“The present study revealed signi^cant improvement of melasma after [Q-switched]

Nd:YAG laser that was proved by mMASI score as well as colorimetric melanin and
erythema indices,” the authors wrote. “This signi^cant outcome was con^rmed by our
simple practical ‘dermoscopic score of pigmentary and vascular elements.’ The

dermoscopic globular and perifollicular pigmentary patterns had showed signi^cant
improvement, a ^nding that might help in deciding the prognosis of melasma.”
The authors say they think they didn’t see signi^cant side effects from treatment
because they used three to four passes compared to the ^ve to 10 passes used by many
other researchers. But they admit their study is limited by its small sample size, small
number of laser sessions and lack of follow up.
Reference:
Abdel Hay, R, Mohammed, FN, Sayed, KS, Abd El Fattah, NA, Ibrahim, S. Dermoscopy as a
useful tool for evaluating melasma and assessing the response to 1064‐nm Q‐switched
Nd:YAG laser. Dermatologic Therapy. 2020;e13629.

Dermoscopy Serves Dual Role in Melasma Management

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Characteristics that distinguish facial hyperpigmentation disorders 17/07/21 09.

Facial pigmentation impacts quality of life

RELATED: How melasma differs in male patients

Looking at patients’ quality of life, which can give dermatologists a perspective on

Dr. Raveendra reports no relevant disclosures.

Raveendra L, Sidappa H, Shree S. A Study of Quality of Life in Patients with Facial

Emerging Agents Augment Melasma Modalities

Her presentation highlighted new solutions to optimize melasma management and

Approaches for Photoprotection

Novel Lightening Agents

In addition to photoprotection, topical lighteners have a cornerstone role in managing

Newer options for treating hyperpigmentation include cysteamine, methimazole,

“Although thromboembolic events are uncommon or rare in studies investigating TA for

Procedural interventions are strategic partners in the multimodality approach for

Maximizing outcomes with peels requires a combination approach, in which a topical

“Whereas we can cure postinUammatory hyperpigmentation of the face often caused by

Download Issue : Dermatology Times, April 2021 (Vol. 42, No. 4)

Laser-assisted delivery of tranexamic acid for

Patients reported an average 9.6-point improvement on the Melasma Quality of Life

Subjects experienced predictable side effects of transient roughness, dryness and

1. Wang, JV, Christman, MP, Feng, H, Ferzli, G, Jeon, H, Geronemus, RG. Laser‐assisted

2. Wanitphakdeedecha, R., Sy-Alvarado, F., Patthamalai, P. et al. The elcacy in treatment

Targeting melasma’s vascular component

Dermatologists should consider assessing melasma patients for increased vascularity

Dermatologists should consider assessing melasma patients for increased vascularity

“Methods of evaluation of the vascular component of melasma are relatively accessible

In a systematic review of 34 published research articles, the authors found strong

Melasma treatment remains challenging despite conventional melasma treatment

“Emerging evidence indicates that melasma pathogenesis may involve aberrant

The authors hypothesize that increased vasculature, vasodilation and inUammation

Histological evaluations and studies looking at proangiogenic and vascular marker

Authors of a diagnostic study found vascular endothelial growth factor (VEGF) is

Researchers have also reported an overexpression of inducible nitric oxide synthase

Studies looking at clinical evidence of vascular characteristics in melasma have found

Researchers have used dermoscopy in diagnostic studies to reveal melasma

“Patients with visibly widened capillaries on dermoscopy showed greater improvements

Which antivascular treatments appear to work?

Authors of a retrospective review studied the elcacy of melasma treatment combining

Researchers have reported improvements in melasma after treatment with the

What should dermatologist to do?

Melasma remains a therapeutic challenge, and dermatologists have easy access to

In addition to physical examination for evaluating melasma lesion vascularity,

“After evaluation of vascularity, dermatologists may then consider adding targeted

1 Masub N, Nguyen JK, Austin E, Jagdeo J. The Vascular Component of Melasma: A

Disclosures: None reported.

Cysteamine cream, tranexamic acid mesotherapy

October 14, 2020

Researchers comparing melasma treatment cysteamine 5% cream to tranexamic acid

Melasma treatment involves reducing melanocyte proliferation and inhibiting

Researchers compared the treatments in a study of predominately female patients

Dermatologists performed mesotherapy on patients randomized to the other group

Larger, carefully designed studies looking at determining optimal dosage, application

Melasma prevalence in Arab-American populations is 13.4 to 15.5%, according to a

These researchers compared the elcacy of tranexamic acid mesotherapy to 0.9%

2. Kaleem S, Ghafoor R, Khan S. Comparison of elcacy of Tranexamic Acid

Disclosure: None declared in the paper.

730 nm picosecond laser safe, effective for

Dermatologists in California did a retrospective review of patients presenting from

In a sub-analysis of improvement scores, they found 76% of patients improved 30% or

“Within the population of patients who developed [post inUammatory hyperpigmentation]

Sunscreen demonstrates strong therapeutic

The importance of blocking visible light in the treatment of pigmentary disorders is

Dermatologists have long recommended sunscreens to prevent worsening of

A more recent paper, published in 2019 in the Indian Journal of Dermatology,