The Burden of Melasma: Race, Ethnicity, and Comorbidities.

INTRODUCTION: In an effort to define the characteristics of populations affected by melasma, we utilized a large global health research network database from 108 health care organizations (TriNetx) to quantify the associations between race, ethnicity, and comorbidities. METHODS: We identified the cohort of all patients with melasma from the TriNetx database, and subsequently generated a control cohort. ICD-10 codes were used to identify the prevalence of various comorbidities associated with melasma. RESULTS: A total of 41,283 patients with melasma (93% female, mean [SD] age 48.8 [12.6] year) were identified. The most frequently associated risk factors included hypertension (25% of the melasma cohort) and hormonal contraception (24%). Rosacea (OR=5.1), atopic dermatitis (OR=3.3), lupus (OR=2.5), history of skin cancer (OR=2.5), history of internal malignancy (OR=2.1), and hormonal contraception use (OR=2.1) possessed the highest odds ratios for development of melasma (all P< 0.01). A statistically significant association was identified for melasma in Asian or Other/Unknown races (OR=2.0 and OR=1.7, P< 0.01), as well as Hispanic ethnicity (OR=1.3, P< 0.01). White, Black/African American, and Not Hispanic groups all revealed slightly lower odds (all 0.8, P< 0.01). CONCLUSION: This latest global update on the etiopathology of melasma further supports findings from prior epidemiologic study reporting preference in melanized phenotypes (Fitzpatrick skin type III-V), but less so in extreme skin types (I, II, VI). Increased associations with rosacea, atopic dermatitis, and history of cancer may emphasize the importance of treating concurrent inflammatory environments and the consideration of more frequent malignancy surveillance. J Drugs Dermatol. 2024;23(8):691-693.  doi:10.36849/JDD.8233.

Chemical Peeling with a Modified Phenol Formula for the Treatment of Facial Freckles on Asian Skin.

BACKGROUND: Chemical peeling is an efficient method for the treatment of pigment disorders. For freckles, medium-depth to deep peeling using a phenol solution is one of the most effective chemical peels, and modifications of facial skin can be observed up to 20 years after peeling. However, applying phenol to the skin may cause serious side effects. Phenol peeling has been rarely used in Asia due to its tendency to cause permanent pigmentary changes and hypertrophic scars. METHODS: In total, 896 Chinese inpatients with facial freckles were enrolled in this study. The phenol formula was modified with crystalline phenol, dyclonine, camphor, anhydrous alcohol and glycerin and adjusted to a concentration of 73.6-90.0%. The entire peeling treatment was divided into two procedures performed separately on 2 days. RESULTS: All patients exhibited 26% or greater improvement, and 99.66% of patients exhibited 51% or greater improvement (good and excellent). Scarring and systemic complications were not observed in any patient. CONCLUSIONS: The modified phenol formula is very effective and safe for the treatment of facial freckles in Asian patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Clinical and Histological Effect of a Low-Fluence Q-Switched 1,064-nm Neodymium: Yttrium-Aluminum-Garnet Laser for the Treatment of Melasma and Solar Lentigenes in Asians: Prospective, Randomized, and Split-Face Comparative Study.

BACKGROUND: The low-fluence Q-switched 1,064-nm neodymium:yttrium-aluminum-garnet laser (QSNYL) is popular for melasma treatment among Asians. OBJECTIVE: This study was to evaluate the clinical and histological effects of the low-fluence QSNYL for treatment of melasma and solar lentigenes. MATERIALS AND METHODS: In this randomized split-face clinical study, 22 patients with melasma or solar lentigo received low-fluence QSNYL weekly for 10 sessions on one cheek. The treatment efficacy was determined by Mexameter skin colorimetry, physician and patient assessment, and by evaluating histological changes. RESULTS: The treated sides had statistically significant reductions in the melanin and erythema indices (EI); 50.0% of melasma and 62.5% of solar lentigo patients had >50% clearance after the final treatment. The increased EI, vascularity, and mast cell activity in patients with melasma and large-sized solar lentigo showed no improvement. The recurrence rates were 16.7% and 12.7% for melasma and solar lentigo, respectively. Postinflammatory hyperpigmentation developed in 1 patient, but no serious side effects were noted. CONCLUSION: Low-fluence QSNYL is effective in treating melasma and small type solar lentigo in Asians. The authors' study also demonstrated that lesion thickness, vascularity, and mast cell activity can be used to predict the efficacy of the treatment of these lesions.

Periorbital melasma: Hierarchical cluster analysis of clinical features in Asian patients.

BACKGROUND: Studies have shown melasma lesions to be distributed across the face in centrofacial, malar, and mandibular patterns. Meanwhile, however, melasma lesions of the periorbital area have yet to be thoroughly described. METHODS: We analyzed normal and ultraviolet light-exposed photographs of patients with melasma. The periorbital melasma lesions were measured according to anatomical reference points and a hierarchical cluster analysis was performed. RESULTS: The periorbital melasma lesions showed clinical features of fine and homogenous melasma pigmentation, involving both the upper and lower eyelids that extended to other anatomical sites with a darker and coarser appearance. The hierarchical cluster analysis indicated that patients with periorbital melasma can be categorized into two clusters according to the surface anatomy of the face. Significant differences between cluster 1 and cluster 2 were found in lateral distance and inferolateral distance, but not in medial distance and superior distance. Comparing the two clusters, patients in cluster 2 were found to be significantly older and more commonly accompanied by melasma lesions of the temple and medial cheek. CONCLUSION: Our hierarchical cluster analysis of periorbital melasma lesions demonstrated that Asian patients with periorbital melasma can be categorized into two clusters according to the surface anatomy of the face.

Oral tranexamic acid (TA) in the treatment of melasma: A retrospective analysis.

BACKGROUND: Melasma is a common pigmentary disorder among Asians and treatment is challenging. Oral tranexamic acid (TA) has emerged as a potential treatment for refractory melasma. Large-scale studies on its use, outcomes, and safety are limited. OBJECTIVE: We sought to evaluate treatment outcomes and adverse effects of oral TA in melasma in an Asian population. METHODS: We conducted a retrospective analysis of patients who received oral TA for melasma in a tertiary dermatologic center from January 2010 to June 2014. RESULTS: In all, 561 patients (91.4% female, 8.6% male) were enrolled. Median duration of treatment was 4 months. The majority (503 [89.7%]) improved, 56 (10.0%) had no improvement, and 2 (0.4%) worsened. Patients without family history of melasma had better response rates than those with family history (90.6% vs 60.0%, P = .01). Of the 503 who improved, response was seen within 2 months of TA initiation, with a relapse rate of 27.2%. Adverse events occurred in 40 (7.1%). Most were transient, but 1 developed deep vein thrombosis requiring prompt discontinuation. She was later given the diagnosis of familial protein S deficiency. LIMITATIONS: This was a retrospective study. CONCLUSION: Oral TA may be an effective adjunct for refractory melasma. Careful screening for personal and familial risk factors for thromboembolism should be done before initiation.

Development and validation of a Hindi language health-related quality of life questionnaire for melasma in Indian patients.

BACKGROUND: Melasma, which is fairly common in Indians, causes significant emotional and psychological impact. A Hindi instrument would be useful to assess the impact of melasma on the quality of life in Indian patients. OBJECTIVE: To create a semantic equivalent of the original MELASQOL questionnaire in Hindi and validate it. METHODS: A Hindi adaptation of the original MELASQOL (Hi-MELASQOL) was prepared using previously established guidelines. After pre-testing, the Hi-MELASQOL questionnaire was administered to 100 women with melasma visiting the out-patient registration counter of Safdarjung Hospital, Delhi. These women were also administered a Hindi equivalent of the Health Related Quality of Life (HRQOL) questionnaire. Melasma area severity index (MASI) of all the participants was calculated. RESULTS: The mean MASI score was 20.0 ± 7.5 and Hi-MELASQOL score was 37.19 ± 18.15; both were highly, positively and significantly correlated. Reliability analysis showed satisfactory results. Physical health, emotional well-being and social life were the most adversely affected life domains. LIMITATIONS: It was a single-center study and the number of patients studied could have been larger. CONCLUSION: Hi-MELASQOL is a reliable and validated tool to measure the quality of life in Indians with melasma.

What's new in objective assessment and treatment of facial hyperpigmentation?

Facial hyperpigmentation is common and challenging to treat in darker-skinned populations. A Medline literature search of articles published up to October 2013 reporting the objective assessment of and/or treatment for melasma, postinflammatory hyperpigmentation, dermatosis papulosa nigra, lichen planus pigmentosus, and erythema dyschromicum perstans was reviewed. Objective assessment was only reported for melasma and postinflammatory hyperpigmentation. Furthermore, randomized controlled trial evidence was only reported for melasma. Although progress has been made, there is a need to develop more objective outcome measures and effective treatments for hyperpigmentation.

An exploratory split-face study of a dual-wavelength laser system on erythromelanosis follicularis faciei in Chinese population.

BACKGROUND: Erythromelanosis follicularis faciei (EFF) is clinically characterized by well-demarcated erythema, hyperpigmentation and follicular papules. No satisfactory therapy has been widely accepted. OBJECTIVE: This study was aimed to evaluate the efficiency and complications of a dual-wavelength laser system in the treatment of EFF in Chinese population. METHODS: Twelve Chinese patients with EFF were enrolled in this study. One side of the face was randomized to receive five successions of treatments at intervals of 6-8 weeks, with the other side spared as control. The parameters were set as follows: energy densities of 6.5-7.5 J/cm(2) with pulsed dye laser (PDL) and 35-50 J/cm(2) with Nd:YAG; pulse duration of 0.5 ms with PDL and 15 ms with Nd:YAG; a delay time of 100 ms between delivery of the two wavelengths. The efficacy was evaluated using subjective assessment and non-invasive measurement. RESULTS: After five sessions of treatment, over 40% patients achieved more than 50% (moderate or significant) improvement. The efficacy maintained at 3-month follow-up. The values of erythema index and melanin index on treated side were significantly less than those on untreated side after sessions of treatments. Adverse effects of treated side were limited. CONCLUSION: Using this split-face module, dual-wavelength laser system treatment is proved to be suitable for Chinese EFF. Adverse effects were minimal.

Use of fractional laser in mixed-race patients.

The use of fractional lasers in mixed race patients has always been a challenge. Post-inflammatory hyperpigmentation or worsening of existing melasma is a risk and its presence can be unpredictable. The authors present their experience in patients with Fitzpatrick skin types IV to VI using fractional lasers. Pre- and post-laser regimens to avoid complications are presented and results are evaluated.

[Melasma and aspects of pigmentary disorders in Asians]. / Mélasma et anomalies pigmentaires chez les asiatiques.

Pigmentary changes in Asians are larger problems and more important features of aging than wrinkles. Melasma is a commonly observed epidermal hypermelanosis of the face in Asians. The altered dermal structures and impaired basement membrane are thought to have an influence on the development of epidermal hyperpigmentation of melasma. Dermal hyperpigmentary diseases are particularly common in Asians. Acquired bilateral melanosis of the neck is a characteristic dermal melanotic condition primarily of the neck in peri-menopausal women. It is characterized by marked accumulation of dermal pigment with perivascular lymphocytic infiltration. The cases seem to represent a continuum of Riehl's melanosis. Subclinical injury or inflammation may play a role as possible causative factors for the development of the pigmentation.

Cystic benign melanosis of the conjunctiva.

PURPOSE: To report the clinical and histologic features of cystic benign melanosis. METHODS: This case series reports on the clinical and histopathologic features of 3 patients with enlarging, cystic, brown, pigmented, conjunctival lesions. RESULTS: Slit-lamp examination showed cystic melanotic lesions of bulbar conjunctiva. Histopathologic examination of the biopsy specimens showed epithelial lined cysts in the substantia propria, goblet cells, and secondary pigmentation of basilar keratinocytes. CONCLUSIONS: Cystic benign melanosis, a unique conjunctival lesion, should be differentiated from cystic nevus and primary acquired melanosis.

Split-face comparative study of 1550 nm fractional photothermolysis and trichloroacetic acid 15% chemical peeling for facial melasma in Asian skin.

Fractional photothermolysis (FP) therapy and chemical peels have been reported to be effective in patients with recalcitrant melasma. However, there is little information to compare the efficacy of single treatment session in Asian women. The aim of this study was to examine the efficacy, long-lasting outcomes and safety of a single session of 1550-nm erbium-doped FP in Asian patients, compared with trichloroacetic acid (TCA) peel with a medium depth. Eighteen Korean women (Fitzpatrick skin type III or IV) with moderate-to-severe bilateral melasma were randomly treated with a single session of 1550-nm FP on one cheek, and with a 15% TCA peel on the other cheek. Outcome measures included an objective melasma area severity index and subjective patient-rated overall improvement at 4 and 12 weeks after treatment. Melasma lesions were significantly improved 4 weeks after either treatment, but melasma recurred at 12 weeks. Post-inflammatory hyperpigmentation developed in 28% of patients at 4 weeks but resolved in all but one patient by 12 weeks. There was no difference between FP treatment and TCA peeling with respect to any outcome measure. FP laser and TCA peel treatments were equally effective and safe when used to treat moderate-to-severe melasma, but neither treatment was long-lasting. We suggest that multiple or periodic maintenance treatments and/or supplemental procedures may be required for the successful treatment of melasma in Asian women.

A retrospective analysis of the management of freckles and lentigines using four different pigment lasers on Asian skin.

BACKGROUND: The risk of post-inflammatory hyperpigmentation (PIH) is increased during freckles and lentigines treatment in Asians. OBJECTIVE: To determine the effectiveness and safety of using 595-nm long pulsed dye laser (LPDL), 755-nm LP Alexandrite laser, 532-nm QS Nd:YAG laser and 532-nm LP potassium-titanyl-phosphate (KTP) laser for the treatment of freckles or lentigines in Asian patients. METHODS: This is a retrospective study of 40 Chinese patients, who were divided into four groups based on treatment modality using four different pigment lasers. Each patient attended between 1 and 4 treatments (mean of 1.8), at 4-6 weeks intervals, depending on clinical response. Lesional clearance and PIH were assessed by two independent clinicians. RESULTS: Statistically significant improvement of global and focal facial pigmentation was found after treatment with LPDL, QS Nd:YAG and LP KTP lasers. No significant improvement was found after LP Alexandrite laser. PIH risk was 20% after LP Alexandrite treatment, 10% with QS Nd:YAG, and absent after LPDL and LP KTP treatment. CONCLUSION: A long pulse laser and small spot size appear to reduce the risks of lentigines treatment in darker skin types.

Melasma and aspects of pigmentary disorders in Asians.

Pigmentary changes in Asians are larger problems and more important features of aging than wrinkles. Melasma is a commonly observed epidermal hypermelanosis of the face in Asians. The altered dermal structures and impaired basement membrane are thought to have an influence on the development of epidermal hyperpigmentation of melasma. Dermal hyperpigmentary diseases are particularly common in Asians. Acquired bilateral melanosis of the neck is a characteristic dermal melanotic condition primarily of the neck in peri-menopausal women. It is characterized by marked accumulation of dermal pigment with perivascular lymphocytic infiltration. The cases seem to represent a continuum of Riehl's melanosis. Subclinical injury or inflammation may play a role as possible causative factors for the development of the pigmentation.

Facial melanoses: Indian perspective.

Facial melanoses (FM) are a common presentation in Indian patients, causing cosmetic disfigurement with considerable psychological impact. Some of the well defined causes of FM include melasma, Riehl's melanosis, Lichen planus pigmentosus, erythema dyschromicum perstans (EDP), erythrosis, and poikiloderma of Civatte. But there is considerable overlap in features amongst the clinical entities. Etiology in most of the causes is unknown, but some factors such as UV radiation in melasma, exposure to chemicals in EDP, exposure to allergens in Riehl's melanosis are implicated. Diagnosis is generally based on clinical features. The treatment of FM includes removal of aggravating factors, vigorous photoprotection, and some form of active pigment reduction either with topical agents or physical modes of treatment. Topical agents include hydroquinone (HQ), which is the most commonly used agent, often in combination with retinoic acid, corticosteroids, azelaic acid, kojic acid, and glycolic acid. Chemical peels are important modalities of physical therapy, other forms include lasers and dermabrasion.

Laser treatment of pigmented lesions for Asians.

The term Asian refers to East Asians of the Pacific Rim who share not only a common heritage and skin type but also the same set of clinical skin problems. Pigmentation of the skin is often considered the number one esthetic skin concern in Asians. Asians idealize unblemished complexion of facial skin and are less tolerant to facial dyschromia than White. The problems of ephelides (freckles), nevi of Ota, and melasma are common and difficult to treat. This article reviews laser treatment of pigmented lesions in Asians.