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Prevention of Melasma in Pregnant Women: Aspects of Approach in Aesthetic Treatment
Abstract
In the gestational period, several changes can occur in the woman's body, almost all the body's systems can undergo modifications, among them is the skin. One of the main changes that occur in the skin is melasma or pregnancy stain, which is the most common in the pigmentary changes of pregnancy. Hyperpigmentations are, in general, disorders distinguished by an increase in melanin and other pigments in the skin. The main triggers for the emergence of melasma are: sex hormones solar radiation and external agents, sources of free radicals. Melasma is characterized by irregularly shaped, brownish melanic pigmentation that appears mainly on the face, and may appear in the 1st or 2nd trimester of pregnancy, especially in women who are of childbearing age and also with phototypes IV and V. During pregnancy, the use of photoprotection correctly is essential for skin protection and to prevent the appearance of melasma, it is always recommended to use sunscreen daily, being applied 30 minutes before sun exposure and reapplying whenever necessary, avoiding the maximum sun exposure between the hours of 10 am to 4 pm. After pregnancy, there may be a large increase in hyperpigmentation, so some professionals indicate treatment after weaning, with some whitening substances such as glycolic acid, azelaic acid, and kojic acid, and can be associated with combined therapy, that is, in some cases, associate diamond pelling, which is a device with a sandpaper at the tip where it produces a sanding in the epidermis. , thus generating cell renewal. It is extremely important that pregnant women receive, at the beginning of pregnancy, all the information on prevention of melasma, and care with adequate photoprotection, thus avoiding psychological suffering and changes in their self-esteem.
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Chemical peels are widely used as therapeutic agents in dermatology and cosmetology. This study aims to explore the differences in the effectiveness of azelaic and pyruvic acid peels in the treatment of acne vulgaris. Eligibility criteria for participants were: female gender, 18–25 years of age, no dermatological treatment within the last 12 months and mild to moderate papulopustular acne. We treated 120 young women (with a mean age of 22 years old) with six peeling sessions at 2-week intervals. In the parallel clinical study design, one randomized group (n = 60, 50%) was treated using azelaic acid (AA), whereas the second group participated in pyruvic acid (PA) sessions. We evaluated the patients clinically twice (before and after treatment), using the Scale of Hellegren–Vincent Severity Symptoms to assess the acne diagnosis, and the Nati Analyzer to estimate the skin properties (oily skin, desquamation, porosity, and moisture). The clinical evaluation of the patients demonstrated a significant reduction of acne severity symptoms in both the AA and PA groups, after the peeling sessions. An effect was also found in terms of decreasing desquamation and the oiliness of the skin. PA showed a more significant reduction of greasy skin than AA. In conclusion, after the six peeling sessions using AA and PA, all patients showed better skin parameters in term of reduced oiliness and desquamation. Both AA and PA peelings are a safe and efficient treatment for mild acne, however, during the selection of one of the two acids, side effects, skin properties, and patients’ preferences should be taken into account. This study was registered in the ISRCTN registry (registration number ISRCTN79716614, 17/01/2020).
Melanogenesis is the process for the production of melanin, which is the primary cause of human skin pigmentation. Skin-whitening agents are commercially available for those who wish to have a lighter skin complexions. To date, although numerous natural compounds have been proposed to alleviate hyperpigmentation, insufficient attention has been focused on potential natural skin-whitening agents and their mechanism of action from the perspective of compound classification. In the present article, the synthetic process of melanogenesis and associated core signaling pathways are summarized. An overview of the list of natural skin-lightening agents, along with their compound classifications, is also presented, where their efficacy based on their respective mechanisms of action on melanogenesis is discussed.
Melasma is a common acquired condition of symmetric hyperpigmentation, typically occurring on the face, with higher prevalence in females and darker skin types. Multiple etiologies, including light exposure, hormonal influences, and family history, have been implicated in the pathogenesis of this disorder. Overall prevalence ranges widely at 1–50%, since values are typically calculated within a specific ethnic population within a geographic region. Histologically, melasma can display increased epidermal and/or dermal pigmentation, enlarged melanocytes, increased melanosomes, solar elastosis, dermal blood vessels, and, occasionally, perivascular lymphohistiocytic infiltrates. Various topical, oral, and procedural therapies have been successfully used to treat melasma. Traditional topical therapies including hydroquinone, tretinoin, corticosteroids, and triple combination creams; however, other synthetic and natural topical compounds have also shown varying efficacies. Promising oral therapies for melasma include tranexamic acid, Polypodium leucotomos, and glutathione. Procedures, including chemical peels, microneedling, radiofrequency, and lasers, are also often used as primary or adjunctive treatments for melasma. Notably, combination therapies within or across treatment modalities generally result in better efficacies than monotherapies. This review serves as a comprehensive update on the current understanding of the epidemiology, pathogenesis, clinical and histologic features of melasma, as well as treatments for this common, yet therapeutically challenging, condition.
Introduction:
Melasma is one of the most common pigmentary disorders seen by dermatologists and often occurs among women with darker complexion (Fitzpatrick skin type IV-VI). Even though melasma is a widely recognized cause of significant cosmetic disfigurement worldwide and in India, there is a lack of systematic and clinically usable treatment algorithms and guidelines for melasma management. The present article outlines the epidemiology of melasma, reviews the various treatment options along with their mode of action, underscores the diagnostic dilemmas and quantification of illness, and weighs the evidence of currently available therapies.
Methods:
A panel of eminent dermatologists was created and their expert opinion was sought to address lacunae in information to arrive at a working algorithm for optimizing outcome in Indian patients. A thorough literature search from recognized medical databases preceded the panel discussions. The discussions and consensus from the panel discussions were drafted and refined as evidence-based treatment for melasma. The deployment of this algorithm is expected to act as a basis for guiding and refining therapy in the future.
Results:
It is recommended that photoprotection and modified Kligman's formula can be used as a first-line therapy for up to 12 weeks. In most patients, maintenance therapy will be necessary with non-hydroquinone (HQ) products or fixed triple combination intermittently, twice a week or less often. Concomitant camouflage should be offered to the patient at any stage during therapy. Monthly follow-ups are recommended to assess the compliance, tolerance, and efficacy of therapy.
Conclusion:
The key therapy recommended is fluorinated steroid containing 2-4% HQ-based triple combination for first line, with additional selective peels if required in second line. Lasers are a last resort.
To evaluate habits of sun exposure and sun protection of pregnant women in a public hospital, to assess orientation about photo protection during the prenatal care, and to detect the presence of melasma and its impact on their quality of life.
A descriptive cross sectional study conducted among women of 18 years old and older, after delivery, who participated in a program of prenatal care in the South Region of Brazil. The sample was non-probabilistic by convenience. Data collection occurred from July to August 2011 through direct interview using a structured questionnaire to obtain personal information and photo protection habits during pregnancy, skin assessment and photographic record of lesions through informed consent. The skin was classified per Fitzpatrick's phototypes and the melasma was diagnosed clinically. In the patients with melasma, the MELASQoL-PB version was applied. The analysis was performed using Statistica, version 8.0, and the significance level of p<0.05.
In the sample (109 mothers) predominated white women (60.6% phototype III), young (average age 24.4 years SD=6.1) and housewives (59.6%). The majority (80%) stayed exposed to sunlight for 1-2 hours per day between 10 am and 3 pm, and from those (72%) did not apply any photoprotection due to lack of sunscreen habit. Other physical means of sun protection were used by 15% of these patients. Information during prenatal care about the risks of sun exposure was reported by 34% of the mothers interviewed. There was a trend toward a significant association between prenatal guidance and daily use of sunscreen (p=0.088). About 20% of mothers had melasma. The average score MELASQol-PB (25) showed a negative impact on quality of life of these patients.
In these women, sun exposure occurred at inappropriate times, without proper guidance and without the use of an effective sunscreen. The mothers with melasma complained about the appearance of their skin, frustration and embarrassment.
Melasma, a hypermelanosis of the face, is a common skin problem of middle-aged women of all racial groups, especially with dark complexion. Its precise etio-pathogenesis is evasive, genetic influences, exposure to sunlight, pregnancy, oral contraceptives, estrogen-progesterone therapies, thyroid dysfunction, cosmetics, and drugs have been proposed. Centro-facial, malar, and mandibular are well-recognized. Epidermal pigmentation appears brown/black, while dermal is blue in color, and can be distinguished by Wood's lamp illumination. The difference may be inapparent with mixed type of melasma in skin types V and VI. An increase in melanin in epidermis: basal and suprabasal layers and/or dermis is the prime defect. There is an increased expression of tyrosinase related protein-1 involved in eumelanin synthesis. The use of broad-spectrum sunscreen is important, lightening agents like retinoic acid (tretinoin), azelaic acid, and combination therapies containing hydroquinone, tretinoin, and corticosteroids, have been used in the treatment of melasma, and are thought to have increased efficacy as compared with monotherapy. Quasi-drugs, placental extracts, ellagic acid, chamomilla extract, butylresorcinol, tranexamic acid, methoxy potassium salicylate, adenosine monophosphate disodium salt, dipropyl-biphenyl-2,2'-diol, (4-hydroxyphenyl)-2-butanol, and tranexamic acid cetyl ester hydrochloride, in addition to kojic and ascorbic acid have been used. Chemical peeling is a good adjunct. Laser treatment is worthwhile.
Melasma is a common hypermelanotic disorder affecting the face that is associated with considerable psychological impacts. The management of melasma is challenging and requires a long-term treatment plan. In addition to avoidance of aggravating factors like oral pills and ultraviolet exposure, topical therapy has remained the mainstay of treatment. Multiple options for topical treatment are available, of which hydroquinone (HQ) is the most commonly prescribed agent. Besides HQ, other topical agents for which varying degrees of evidence for clinical efficacy exist include azelaic acid, kojic acid, retinoids, topical steroids, glycolic acid, mequinol, and arbutin. Topical medications modify various stages of melanogenesis, the most common mode of action being inhibition of the enzyme, tyrosinase. Combination therapy is the preferred mode of treatment for the synergism and reduction of untoward effects. The most popular combination consists of HQ, a topical steroid, and retinoic acid. Prolonged HQ usage may lead to untoward effects like depigmentation and exogenous ochronosis. The search for safer alternatives has given rise to the development of many newer agents, several of them from natural sources. Well-designed controlled clinical trials are needed to clarify their role in the routine management of melasma.
Chloasma is a required hypermelanosis of sun-exposed areas occurred during pregnancy and it can affect 50–70% of pregnant women. It presents as symmetric hyperpigmented macules, which can confluent or punctuate. The most common locations are the cheeks, the upper lip, the chin and the forehead. The exact mechanism by which pregnancy affects the process of melanogenesis is unknown. Estrogen, progesterone, and melanocyte-stimulating hormone (MSH) levels are normally increased during the third trimester of pregnancy. However, nulliparous patients with chloasma have no increased levels of estrogen or MSH. In addition, the occurrence of melasma with estrogen- and progesterone-containing oral contraceptive pills has been reported. The observation that postmenopausal woman who are given progesterone develop melasma, while those who are given only estrogen do not, implicates progesterone as playing a critical role in the development of melasma. UV-B, UV-A, and visible light are all capable of stimulating melanogenesis. The condition is self-limited; however spontaneous resolution is time-consuming and may take months to resolve normal pigmentation. Therefore, it is worthwhile to prevent the onset of chloasma, by strict photoprotection. Prudent measures to avoid sun exposure include hats and other forms of shade combined with the application of a broad-spectrum sunscreen at least daily. Sunscreens containing physical blockers, such as titanium dioxide and zinc oxide, are preferred over chemical blockers because of their broader protection. Chloasma can be difficult to treat. Quick fixes with destructive modalities (eg, cryotherapy, medium-depth chemical peels, lasers) yield unpredictable results and are associated with a number of potential adverse effects. The mainstay of treatment remains topical depigmenting agents. Hydroquinone (HQ) is most commonly used.
A series of diarylpropane compounds was isolated by screening a plant extract library for inhibitors of mushroom tyrosinase. The most potent compound, 1-(2,4-dihydroxyphenyl)-3-(2,4-dimethoxy-3-methylphenyl)propane (UP302: CAS# 869743-37-3), was found in the medicinal plant Dianella ensifolia. Synthetic and plant-derived versions of UP302 inhibited mushroom tyrosinase with similar potencies. UP302 inhibited mushroom tyrosinase with K(i)=0.3 microM, in a competitive and reversible fashion. UP302 was 22 times more potent than Kojic acid in inhibiting murine tyrosinase, with IC(50) values of 12 and 273 microM respectively. Experiments on mouse melanoma cells B16-F1 and on human primary melanocytes demonstrated that UP302 inhibits melanin formation with IC(50) values of 15 and 8 microM respectively. Long-term treatment of cultured melanocytes with up to 62 microM of UP302 revealed no detectable cytotoxicity. In a reconstructed skin model (MelanoDerm) topical application of 0.1% UP302 resulted in significant skin lightening and decrease of melanin production without effects on cell viability, melanocyte morphology or overall tissue histology. In conclusion, UP302 is a novel tyrosinase inhibitor that suppresses melanin production in both cultured melanocytes and reconstructed skin with high potency and without adverse side effects.
Tyrosinase is responsible for the molting process in insects, undesirable browning of fruits and vegetables, and coloring of skin, hair, and eyes in animals. To clarify the mechanism of the depigmenting property of hydroxystilbene compounds, inhibitory actions of oxyresveratrol and its analogs on tyrosinases from mushroom and murine melanoma B-16 have been elucidated in this study. Oxyresveratrol showed potent inhibitory effect with an IC(50) value of 1.2 microm on mushroom tyrosinase activity, which was 32-fold stronger inhibition than kojic acid, a depigmenting agent used as the cosmetic material with skin-whitening effect and the medical agent for hyperpigmentation disorders. Hydroxystilbene compounds of resveratrol, 3,5-dihydroxy-4'-methoxystilbene, and rhapontigenin also showed more than 50% inhibition at 100 microm on mushroom tyrosinase activity, but other methylated or glycosylated hydroxystilbenes of 3,4'-dimethoxy-5-hydroxystilbene, trimethylresveratrol, piceid, and rhaponticin did not inhibit significantly. None of the hydroxystilbene compounds except oxyresveratrol exhibited more than 50% inhibition at 100 microm on l-tyrosine oxidation by murine tyrosinase activity; oxyresveratrol showed an IC(50) value of 52.7 microm on the enzyme activity. The kinetics and mechanism for inhibition of mushroom tyrosinase exhibited the reversibility of oxyresveratrol as a noncompetitive inhibitor with l-tyrosine as the substrate. The interaction between oxyresveratrol and tyrosinase exhibited a high affinity reflected in a K(i) value of 3.2-4.2 x 10(-7) m. Oxyresveratrol did not affect the promoter activity of the tyrosinase gene in murine melanoma B-16 at 10 and 100 microm. Therefore, the depigmenting effect of oxyresveratrol works through reversible inhibition of tyrosinase activity rather than suppression of the expression and synthesis of the enzyme. The number and position of hydroxy substituents seem to play an important role in the inhibitory effects of hydroxystilbene compounds on tyrosinase activity.
Melasma (or chloasma) is a common disorder of cutaneous hyperpigmentation predominantly affecting sun-exposed areas in women. The pathogenesis of melasma is not fully understood and treatments are frequently disappointing and often associated with side effects.
Pycnogenol® is a standardized extract of the bark of the French maritime pine (Pinus pinaster), a well-known, potent antioxidant. Studies in vitro show that Pycnogenol® is several times more powerful than vitamin E and vitamin C. In addition, it recycles vitamin C, regenerates vitamin E and increases the endogenous antioxidant enzyme system. Pycnogenol® protects against ultraviolet (UV) radiation. Therefore its efficacy in the treatment of melasma was investigated.
Thirty women with melasma completed a 30-day clinical trial in which they took one 25 mg tablet of Pycnogenol® with meals three times daily, i.e. 75 mg Pycnogenol® per day. These patients were evaluated clinically by parameters such as the melasma area index, pigmentary intensity index and by routine blood and urine tests.
After a 30-day treatment, the average melasma area of the patients decreased by 25.86 ± 20.39 mm2 (p < 0.001) and the average pigmentary intensity decreased by 0.47 ± 0.51 unit (p < 0.001). The general effective rate was 80%. No side effect was observed. The results of the blood and urine test parameters at baseline and at day 30 were within the normal range. Moreover, several other associated symptoms such as fatigue, constipation, pains in the body and anxiety were also improved.
To conclude, Pycnogenol® was shown to be therapeutically effective and safe in patients suffering from melasma. Copyright
Hyperpigmentation in pregnancy is a common phenomenon, experienced to some degree by up to 90% of pregnant women. It mainly involves sun-exposed areas, but it can extend to non-exposed zones. Cases with extensive hyperpigmentation are rarely reported. In this paper, we describe the case of a 30-year-old phototype V woman in her 37th week of pregnancy, who presented with brownish hyperpigmentation of the skin in extensive areas, including both axillae, the abdomen, and the lowest part of the back. In the abdomen, there was a reinforcement of the hyperpigmentation through the linea nigra and the umbilicus. The hyperpigmentation affected the buttocks as well and involved the intertriginous area between them. Histopathologic analysis showed a hyperpigmented basal layer of the epidermis with no melanocytic atypia or melanocytic nests. Histochemical staining for iron did not show any deposits. Immunohistochemical studies for HMB-45, Melan A, and SOX10 demonstrated an increased number of melanocytes. There was hyperpigmentation of basal layer keratinocytes.. We also performed immunohistochemical stains for estrogen and progesterone receptors, which were both negative. The patient was examined 3 months after delivery, evidencing a significant clearing of the lesions.
Background:
Melasma is a challenging dermatological condition during pregnancy. The aim of this study was to determine the clinical efficacy of a topical liposome encapsulated Aloe vera preparation, on melasma in pregnant women. In order to enhance the bioavailability of Aloe vera leaf gel extract (AGE), liposomes encapsulating Aloe vera were prepared and examined for their biochemical properties.
Methods:
In this double-blinded, randomized clinical trial, two groups of pregnant women with melasma who were at their second trimester of pregnancy or later were studied. They received liposome encapsulated AGE (in the form of gel), 90 patients in each of the experimental and control group for 5 weeks respectively. The liposomes was prepared from a soybean lecithin (SLP-WHITE, 1.0 wt%), with a high trapping efficiency up to 0.5 wt% AGE concentration. The stable liposomes were then prepared from 1.0 wt% of SLP-WHITE, and different concentrations of AGE was prepared by mechanochemical method using a microfluidizer and homogenizer. The liposomes obtained from 0.25 wt% of AGE were confirmed to be small unilamellar vesicles with a diameter <200 nm, which remained well dispersed for at least two weeks. Our results are expressed as Mean (±SD), the MASI (Melasma Area Severity Index) score was used to record melasma severity and ANCOVA was used for data analysis.
Results:
After 5 weeks of melasma treatment in pregnant women, there was a 32% improvement in the MASI score in the liposomal-AGE treatment group compared with a 10% improvement in the AGE group standalone. The prevalence of melisma decreases with an increase in parity, i.e 39(43.35%), 34(37.8%), 15(16.7%) and 2(2.2%) for the experimental groups, and 45(50%), 35(38.9%), 10(11.1%) and 0(0%) for the control group (P=0.32). There was significant difference between experimental and control groups in terms of mean MASI score after the trial. There was no significant difference between the groups regarding family history of melasma, occupation, frequency of sunscreen usage, and hours of sun exposure. However, within each groups, there was a slight to great significant difference observed.
Conclusion:
Liposome encapsulated Aloe vera gel extract was superior to AGE in decreasing the severity of melasma in pregnancy due to their ease in percolation, it ligtens the melasma, with only mild side effects.
Background:
Tyrosinase is an enzyme involved in the first steps of the melanogenesis process. It catalyzes the hydroxylation of monophenols to o-diphenols and the oxidation of the latter to o-quinones. Ellagic acid (EA) is a phenolic compound which has been described as a tyrosinase inhibitor and is used in the cosmetic industry as a whitening agent. However, it has hydroxyl groups in ortho position and could act as a substrate rather than inhibitor. This aspect should be taken into consideration when using this compound as a cosmetic ingredient due to the reactive character of o-quinones.
Objective:
To determine whether ellagic acid is a substrate or an inhibitor of tyrosinase, to characterize it kinetically and interpret its role in the melanogenesis process.
Methods:
UV-vis spectrophotometry was used to follow the action of tyrosinase on typical substrates and ellagic acid. A chronometric method was chosen for the kinetic characterization of ellagic acid.
Results:
Ellagic acid is not an inhibitor per se but an alternative substrate of tyrosinase. It is oxidized by the enzyme to an unstable o-quinone. Its kinetic characterization provided low Michaelis and catalytic constants (KM(EA)=138±13μM and kcat(EA)=0.47±0.02s(-1)). Furthermore, ellagic acid, which is a powerful antioxidant, may chemically reduce the o-quinones (o-dopaquinone) and semiquinones, in this way inhibiting the melanogenesis.
Conclusion:
Ellagic acid is oxidized by tyrosinase, producing reactive o-quinones. As an antioxidant it can inhibit the melanogenesis process. This first aspect should be taken into consideration in its application as a cosmetic ingredient due to the toxicity of o-quinones and its ability to modify the redox status of the cell.
Introduction: Melasma is the principal cause of facial hyperchromia and has a signifi cant psychosocial impact. Wood's lamp has been a useful device to estimate the depth of melanin determined by light-induced fl uorescence. A dermatoscope enables a clear visualization of pigments distribution, and the color variation of melanin will depend on its location within the skin. Objective: Evaluate the classifi cation of melasma according to depth of melanin by dermatoscopy and to correlate the dermatoscopic fi ndings with its classifi cation using Wood's lamp. Material and methods: Analysis of concordance between dermatoscopy and Wood's lamp in the classifi cation of melasma. Forty patients were evaluated by expert examiners, using a Wood's lamp (Burton® UVA 360nm LE T5 4W BLB) and dermoscopy (Bley Med-Skincam® 40x or 3Gen Dermlite II ProHR® 10x), in an independent manner. The epidermal type was considered as the presence of a regular pigment network, with a brownish homogeneous pigmentation; dermal type as an irregular and mixed network with bluish-gray pigmentation; and mixed type as areas presenting both features. Results: The degree of concordance between the methods was considered weak (k < 0.2) by statistical analysis. Conclusions: The authors consider the technique more suitable, since it has allowed the visualization of the pigmentary components in a more objective way.
Multiple treatments exist for melasma; they are often substandard and associated with side effects.
We sought to assess the effectiveness of interventions used in the management of all types of melasma.
We undertook a systematic review using the methodology of the Cochrane Collaboration.
We included 20 studies with a total of 2125 participants covering 23 different treatments. A meta-analysis was not possible because of the heterogeneity of treatments. Triple-combination cream (hydroquinone, tretinoin, and fluocinolone acetonide) was more effective at lightening melasma than hydroquinone alone (relative risk 1.58, 95% confidence interval 1.26-1.97) or any of the agents in a dual-combination cream. Azelaic acid (20%) was significantly more effective than 2% hydroquinone (relative risk 1.25, 95% confidence interval 1.06-1.48) at lightening melasma. In 2 studies where tretinoin was compared with placebo, objective measures demonstrated significant reductions in the severity. However, only in 1 study did participants rate a significant improvement (relative risk 13, 95% confidence interval 1.88-89.74).
There was poor methodology, a lack of standardized outcome assessments, and short duration of studies.
The current limited evidence supports the efficacy of multiple interventions. Randomized controlled trials on well-defined participants with long-term outcomes are needed.
Safety of cosmetic procedures in pregnant women has not been extensively studied. Maternal and fetal health risks are important to consider in any procedure performed. With the increasing popularity of cosmetic procedures, dermatologic surgeons will be faced with scenarios necessitating knowledge regarding the safety of such procedures during pregnancy. Furthermore, dermatologic surgeons may inadvertently perform cosmetic procedures during the first trimester, before the patient is aware of the pregnancy.
To investigate the safety of cosmetic procedures during pregnancy and the postpartum period.
A literature search of PubMed and Google Scholar was conducted of all English-language articles published from 1960 through 2012.
Definitive recommendations on the safety of procedures such as chemical peels, injectables, fillers, and most laser therapies during pregnancy cannot be made. The safety of onabotulinum toxin usage is well documented in the neurology literature, although isolated events of miscarriage have been reported with high doses of toxin in women with a previous history of miscarriage. Carbon dioxide laser therapy for genital condylomas has considerable evidence supporting its safety during pregnancy.
There is a lack of controlled trials addressing the safety of cosmetic procedures during pregnancy and postpartum periods. It is advisable to delay elective cosmetic procedures until after the baby is born.
Facial hyperpigmentation occurs in multiple conditions. In addition, many Asian women desire a lighter skin color. Thus, there is a need for the development of skin lightening agents, and niacinamide and tranexamic acid (TXA) are promising candidates.
To assess the effectiveness of a combination of niacinamide and TXA as a topical moisturizing formulation for treatment of irregular facial pigmentation.
A total of 42 Korean women (age range: 30-60 years) who were not pregnant, nursing, or undergoing any concurrent therapy were enrolled in this study for 8 weeks. Subjects used a twice-daily regimen of either a moisturizing cream containing 2% niacinamide + 2% TXA (test formulation; n = 21) or cream vehicles (vehicle control; n = 21) in addition to an assigned sunscreen each morning. Pigmentation was measured objectively using a mexameter and chromameter, in addition to physicians' assessment using clinical photographs.
The niacinamide + TXA formulation regimen was significantly (P < 0.05) more effective than the vehicle control formulation regimen in reducing the appearance of pigmentation.
A formulation containing the combination of niacinamide + TXA reduced the appearance of irregular pigmentation, providing an effect beyond that achieved with sunscreen.
Dermatologic surgery is changed in the pregnant and postpartum patient. The physiologic changes associated with pregnancy require attention to the timing of surgery as well as the positioning and technique to maximize the outcome for the patient. The surgeon must also remember the risks to the fetus or nursing newborn in planning any surgical procedure. This is the one time when there is more than one patient in every procedure. This article will review the timing of surgery, tumors of pregnancy, surgical positioning, local anesthetics, surgical technique, and cosmetic procedures. This information should help provide a safe surgical procedure for the mother and the child.
Hyperpigmentation of the skin is a common dermatologic condition in all skin types but most prominent in brown-skinned population. In skin of color any inflammation or injury can be accompanied by alterations in pigmentation (hyper/hypo-pigmentation). Postinflammatory hyperpigmentation (PIH) can be observed in many skin conditions including acne, eczema, and contact dermatitis. In the control of skin pigmentation, parallel to the cross-talk between keratinocytes and melanocytes, increasing evidence has underlined the crucial role exerted by the interactions between mesenchymal and epithelial cells through the release of fibroblast-derived growth factors. Among these factors, the keratinocyte growth factor (KGF), alone or in combination with interleukin-1α, induces melanin deposition in vitro and hyperpigmented lesions in vivo. Furthermore, a moderate increase of KGF and a high induction of its receptor have been shown in solar lentigo lesions, suggesting the involvement of this growth factor in the onset of the hyperpigmented spots. Several studies highlight the possible contribution of the fibroblast-derived melanogenic growth factors to the hyperpigmentated lesions, in the context of the mesenchymal - epithelial interactions modulating melanocyte functions.
Copyright © 2012 Elsevier Masson SAS. All rights reserved.
Excessive exposure to solar or artificial sources of UV radiation is deleterious to the skin and can cause or worsen several diseases. Detrimental effects of UV radiation exert an important role in the development of skin cancers, cause alterations on the immune response, and act as a trigger or aggravating factor for pigmentary disorders. A group of measures, including education, change of habits, use of physical barriers and sunscreens constitutes a significant part of the treatment of many skin disorders and are valuable preventive tools. This article summarizes the relevant studies addressing these issues, emphasizing the many aspects of photoprotection.
Copyright © 2012 Elsevier Masson SAS. All rights reserved.
The occurrence of abnormally pigmented skin lesions is a common phenomenon and often associated with the influence of ultraviolet radiation (UV) and other sources of DNA damage. Pigmentary lesions induced by UV radiation and other sources of DNA damage occur in healthy individuals, but human diseases with defective DNA repair represent important models which allow the investigation of possible underlying molecular mechanisms leading to hypo- and hyperpigmentations. There are several hereditary diseases which are known to go along with genetic defects of DNA repair mechanisms comprising Xeroderma pigmentosum (XP), Cockayne syndrome (CS), Trichothiodystrophy (TTD), Werner syndrome (WS), Bloom syndrome (BS), Fanconi anemia (FA) and Ataxia telangiectasia (AT). These diseases share clinical characteristics including poikilodermatic skin changes such as hypo-and hyperpigmentation. Since UV radiation is the most common source of DNA damage which can cause pigmentary lesions both in healthy individuals and in patients with genetic deficiency in DNA repair, in the present article, we focus on pigmentary lesions in patients with XP as an example of a disease associated with genetic defects in DNA repair.
Copyright © 2012 Elsevier Masson SAS. All rights reserved.
Hyperpigmentations are very frequent situations that can have considerable impact on the quality of life of affected individuals. However, even if the esthetic prejudice they generate is undeniable, lentigo and melasma are benign conditions that require above all a risk-free management. In addition to the dermatological procedures (peeling, laser, etc.) and the topical drugs available to the dermatologist, there remains significant room for depigmenting dermocosmetic products. These products succeeded to transpose features of the classic pharmaceutical formula invented by Kligman from which they were inspired to the field of dermocosmetics. They comprise activators of epidermal turn-over, skin exfoliants, and active ingredients that interfere with the different stages of melanogenesis, without having the side effects of hydroquinone whose usage remains limited to the field of prescription drugs. Antioxidants are a particularly interesting addition because they participate in reducing cutaneous inflammation and efficiently complete the action of the other components of a depigmenting formula. It is important to remind the aggravating role that sun exposure has on hyperpigmentations. Therefore, measures of rigorous photoprotection are mandatory. Medical makeup, transitory or definite, is an interesting option for the management of hyperpigmentations. Consequently, depigmenting dermocosmetics, used in monotherapy but - most frequently - in combination with dermatological procedures, can be used in literally all types of hyperpigmentations with an efficacy that is dependent on the specific etiology. They are suited to be part of a treatment program that has to be adapted on a case-by-case basis.
Copyright © 2012 Elsevier Masson SAS. All rights reserved.
Melasma is a cosmetic problem that sometimes causes great emotional suffering. The two most important causative factors are sunlight and genetic predisposition. Moreover, natural and synthetic estrogens, the use of certain drugs and the use of cosmetics with certain components have been implicated as etiologic factors. For the treatment of melasma, the elimination of the factors that are associated with the abnormality of pigmentation, is essential (discontinuation of birth control pills, avoidance of sun exposure). From the many medications that have been used in the treatment of melasma, Hydroquinone alone at a concentration of 2-5%, or in combination with tretinoin or tretinoin and corticosteroids, is now the most widely used preparations. New phenolic compounds and Azelaic acid are also used. Medium depth chemical peeling alone or in combination with other bleaching agents has also been tried with success in some cases. Finally, the use of lasers is discussed.
Melasma is an acquired brown hypermelanosis of the face. Although it is thought that melasma is associated with multiple etiologic factors (pregnancy, genetic, racial, and endocrine), one of the primary causes of its exacerbation appears to be exposure to sunlight. Three patterns of melasma are recognized clinically: (1) a centrofacial pattern, (2) a malar pattern, and (3) a mandibular pattern. Examination of patients with Wood's light (320–400 nm) is useful in classifying the specific type of melasma in correlation with the localization of pigment granules (melanosomes) in the epidermis and dermis. Four types of melasma are described on the basis of Wood's light examination: (1) an epidermal type, (2) a dermal type, (3) a mixed type, and (4) a fourth type, described in patients of dark complexion, in which the lesions, for lack of contrast, are not discernible on Wood's light examination, perhaps due to the increased number of melanosomes in the normal skin of black individuals. Light, histochemical, and electron microscopic studies revealed an increase in number and activity of type-specific melanocytes which appeared to be engaged in increased formation, melanization, and transfer of pigment granules (melanosomes) to the epidermis as well as to the dermis. The melanocyte seems to undergo a functional alteration brought about by a combination of multiple factors, including persistent sun exposure, hormonal factors, and genetic predisposition.
Knowledge of the histopathology of melasma is a prerequisite for understanding its pathogenesis. However, the histopathological characteristics of male melasma are not well characterized.
We sought to investigate the histopathological characteristics of melasma in men compared with those of women with melasma and solar lentigo.
Biopsy specimens were obtained from both the lesional skin and the adjacent nonlesional skin in 8 men with melasma, 10 women with melasma, and 5 men and women each with solar lentigo. The samples were stained using Fontana-Masson and Verhoeff-van Gieson. Immunohistochemistry for melanocytes, the estrogen receptor, progesterone receptor, factor VIIIa-related antigen, stem cell factor, and c-kit was performed.
Increased vascularity was found in the lesion of male melasma. The lesion to nonlesion ratio of the vessel area was increased in male melasma compared with lentigo groups. In the lesion of male melasma, there was a significant increase of stem cell factor and c-kit expression. In addition, the lesion to nonlesion ratio of stem cell factor was increased in male melasma compared with female melasma and lentigo groups. The lesion to nonlesion ratio of c-kit was also increased in male melasma compared with lentigo groups.
This study did not include clinical data regarding social habits and was not confirmed by other molecular techniques.
The results suggest that chronic ultraviolet radiation associated with signaling of paracrine cytokines plays an important role in the mechanism associated with hyperpigmentation in male melasma.
Melasma is a common condition affecting over six million American women. Treatment of dermal or combined melasma is difficult and does not respond well to conventional topical therapies. Various light sources have been used recently in the treatment of melasma including fractionated ablative and non-ablative lasers as well as intense pulse light. We report the use of low fluence, large spot size Q-switched, Nd:Yag laser for the treatment of melasma in skin types II-IV.
Melasma is a common disorder in women of reproductive age with darker skin tones, but may also affect adolescents, older women on certain medications, and sometimes men. It usually appears as hyperpigmented macules and patches distributed symmetrically on the face, neck and rarely the upper limbs. Although its pathogenesis remains unclear, known risk factors include ultraviolet (UV) radiation, hormonal variations of pregnancy and thyroid disease, and anti-seizure medications. The increase in melanin may be due to both an increase in melanogenesis and melanocytosis. Prevention should target a reduction of exposure to risk factors, such as consistent protection against UV radiation. The principle treatment options include topical hypopigmenting agents, chemical peels, laser therapy and superficial dermabrasion. The impact of melasma on the quality of life of patients should be considered.
Pregnancy is a period of profound endocrine and metabolic changes which are tolerated by the body for a relatively short time. During gestation both physiologic and pathologic changes can occur in the skin, nails, and hair shafts which should be recognized and appropriately managed by the dermatologist. These changes can conveniently be placed into five broad categories: (1) physiologic changes in skin and appendages caused principally by the hormonal milieu, (2) cutaneous tumors affected by pregnancy, (3) diseases specifically associated with pregnancy, (4) genital infections of perinatal importance, and (5) other dermatologic diseases influenced by pregnancy. A discussion of each of these topics reveals the vast spectrum of dermatologic disease seen in pregnancy and underscores the important role of the dermatologist in the care of pregnant patients.
To compare, in a double-blind, randomized, prospective study, the clinical improvement of hyperpigmentation in 30 patients with melasma using hydroquinone or skin whitening complex topically on one side of the face vs. a placebo cream on the other. The study was performed during the period November 2000 to March 2001 at the Federal University of São Paulo, Escola Paulista de Medicina.
Thirty patients received three tubes of cream and were divided into two groups: group 1, one tube containing hydroquinone 4% cream and one tube containing placebo to be applied to opposite sides of the face at night, and standardized sunscreen [sun protection factor (SPF) 25] for daily use; group 2, one tube containing skin whitening complex 5% cream and one tube containing placebo to be applied to opposite sides of the face at night, and standardized sunscreen (SPF 25). All of the tubes had the same appearance and the creams had the same characteristics. The only person who knew what was being used by each patient on each side of the face was the pharmacist. A professional photographer took photographs before and after treatment, which lasted for 3 months. Clinical evaluation was performed by two independent observers and by the patients themselves. Statistical evaluation was by the chi-squared and kappa methods.
Twenty-five patients completed the study, with an overall improvement of 72% in comparison with placebo. Group 1 (hydroquinone and placebo) presented an improvement of 76.9% with 25% side-effects, and group 2 (skin whitening complex and placebo) presented an improvement of 66.7% with 0% side-effects.
Both depigmentation agents were useful in the treatment of melasma. The hydroquinone group presented more collateral effects than the skin whitening complex group. Considering that the patients showed Fitzpatrick skin types IV to VI and the study was conducted in the summer, skin whitening complex seems to be an excellent choice for the treatment of melasma.
Melasma is an irregular brown or grayish-brown facial hypermelanosis, often affecting women, especially those living in areas of intense UV radiation. The precise cause of melasma remains unknown; however, there are many possible contributing factors. Because of its dermal component and tendency to relapse, melasma is often difficult to treat. The use of broad-spectrum (UVA + UVB) sunscreen is important, as is topical hydroquinone, the most common treatment for melasma. Other lightening agents include retinoic acid (tretinoin) and azelaic acid. Combination therapies such as hydroquinone, tretinoin, and corticosteroids have been used in the treatment of melasma, and are thought to increase efficacy as compared with monotherapy. Kojic acid, isopropylcatechol, N-acetyl-4-cysteaminylphenol, and flavonoid extracts are other compounds that have been investigated for their ability to produce hypopigmentation, but their efficacy, safety, or trial design indicates that the interventions would need further study before they could be recommended. Chemical peels, laser treatments, and intense pulsed light therapy are additional therapeutic modalities that have been used to treat melasma.
Melasma (cloasma) is a typical hypermelanosis and a common dermatologic skin disease that involves sun-exposed areas of the skin. It mostly affects women of reproductive age. Solar and ultraviolet exposure are the most crucial etiologic factors. Pregnancy, certain endocrine disorders and hormonal treatments, cosmetics, phototoxic drugs, and antiseizure medications are well-known inducing and exacerbating factors. A classification of melasma is based on Wood's light examination, classifying it in four major clinical types and patterns: epidermal, dermal, mixed, and indeterminate. Different treatment options are currently available for melasma. The choice of proper treatment should take into account the type of melasma to be treated, the skin complexion of the patient, possible previous treatments, the expectations and compliance of the patient, and the season in which the treatment is started.
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