Facial pigmentation impacts quality of life regardless of clinical severity 17/07/21 09.

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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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“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.

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Facial pigmentation impacts quality of life regardless of clinical severity 17/07/21 09.36

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

identi^ed 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.

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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:

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Facial pigmentation impacts quality of life regardless of clinical severity 17/07/21 09.36

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

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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 satis^ed 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, modi^ed 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.

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“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.

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