Definition of refractory melasma and its treatment: a review.

Although patients with refractory melasma have been treated using various methods, there is still no precise definition or summary of the therapies. To define refractory melasma and conduct a review of the treatments, we searched for relevant publications in PubMed, Web of Science, and the Cochrane Library, and a total of 35 references were obtained. Refractory melasma can be roughly defined as an ineffective treatment for melasma, including topical bleaching agents, chemical peels, laser therapy, microdermabrasion for more than six months, or chemical peels treated more than six times. Meanwhile, physicians should be careful when treating patients with darker skin and dermal or mixed types of melasma since these individuals do not respond well to treatment. Lasers combined with other methods, especially different types of lasers or topical agents, are considered more effective than monotherapy. Oral tranexamic acid (TXA) is a prospective cure for refractory melasma. Other methods include a combination of chemical peels, microneedling, or injections with additional therapies. In conclusion, we were able to provide a rough definition of refractory melasma and list the available therapies. According to the literature, the most prevalent treatment is laser combination therapy. However, laser treatment should be considered only after topical agents and chemical peeling have failed. Considering its side effects, efficacy, and safety, oral TXA may be a better option, but more research is needed to make a firm conclusion. Moreover, maintenance therapy is required after treatment.

Detection and Analysis of Commonly Used Infection Indicators in Patients with Acute Urticaria.

INTRODUCTION: In this study, we investigated the correlation and clinical significance of peripheral blood leukocytes, neutrophils, C-reactive protein (CRP), and procalcitonin (PCT) in patients with acute urticaria. METHODS: Complete blood count with differential, CRP, and PCT tests were conducted on patients with acute urticaria. A total of 614 patients with acute urticaria were divided into three groups: the first group consisted of patients with elevated leukocyte and neutrophil count, the second group consisted of patients with normal leukocyte and neutrophil count, and the third group consisted of patients with abnormal leukocyte and neutrophil count. A correlation analysis was conducted to investigate the levels of leukocytes, neutrophils, CRP, and PCT in the three groups. RESULTS: The results of Kruskal-Wallis' nonparametric test revealed statistically significant variations in leukocytes, neutrophils, CRP, and PCT among the three groups (p < 0.001). However, CRP and PCT showed no statistically significant differences between the second and third groups (p < 0.001, p = 0.0041, p = 0.0032). Additional multiple comparisons in Spearman correlation analysis indicated statistically significant differences (p = 0.55). Across all groups, there was a statistically significant difference in the correlation between CRP-PCT and leukocytes-neutrophils (p = 0.53). CONCLUSION: Leukocytes and neutrophils are sensitive to the impact of medications and stress on the body. Combining CRP and PCT, as well as routine blood test, may be a comprehensive assessment of infection presence and severity in patients, providing guidance for antibiotic treatment.

Body dysmorphic disorder symptoms in patients with melasma.

BACKGROUND: Body dysmorphic disorder (BDD) is a psychiatric condition characterized by extreme preoccupation with non-existent or minor defects in appearance, disrupting daily functioning. Melasma is a common concern among BDD patients with dermatological conditions. This study aimed to estimate the incidence and characteristics of BDD in patients with melasma, and compare the psychological condition of patients and age- and sex-matched healthy controls. METHODS: Patients with melasma and healthy controls were screened using the BDD Questionnaire (BDDQ), Self-rating Anxiety Scale (SAS), and Self-rating Depression Scale (SDS). A questionnaire was administered to collect demographic information and clinical characteristics. Standard statistical tests were conducted, such as descriptive analysis, chi-square, and nonparametric tests. The level of statistical significance for all tests was set at a P < 0.05. RESULTS: Among the 470 patients with melasma included in the study, 53 were positive for BDDQ in the preliminary screening and were associated with a history of treatment, higher Melasma Area and Severity Index (MASI), and Melasma Quality of Life (MELASQoL) scores, and higher SAS and SDS scores. The positive rate of BDDQ ranged from 0.4%, using the most stringent criteria to assess melasma severity, to 11.3%, without using objective criteria. Compared to healthy controls, patients with melasma had a higher positive rate of BDDQ and higher SAS and SDS scores. CONCLUSION: In patients with melasma who exaggerate the severity of the disease, psychiatric treatment and the patient-physician relationship have a positive effect. This study assessed the positive rate of BDDQ in melasma and proposed the feasibility of psychiatric treatment for patients with melasma.

Changes of Facial Lipidomics by Intense Pulsed Light Treatment Based on LC-MS.

BACKGROUND: Intense pulsed light (IPL) has been widely used to improve cutaneous photoaging in recent years. Several studies began to explore the changes of skin barrier function after treatment, but the changes of skin surface lipids (SSL), especially specific lipid content and types are still unclear. METHODS: A total of 25 female volunteers were included in our study, and each of them received three full-face treatments with one month apart. Before the first treatment and 1 month after the last treatment, we collected clinical photos and skin stratum corneum samples from individuals. A 5-level scale was used to evaluate the efficacy of IPL treatment, liquid chromatography-mass spectrometry (LC-MS), and Orthogonal Partial Least Squares Discrimination Analysis (OPLS-DA) were used to analyze the changes of SSL. RESULTS: Two patients got no improvement after treatment, 6 patients had poor improvement and mild improvement was achieved in 9 patients, 5 and 3 patients reported moderate and significant improvement. The overall "effective" rate was 68 % and the "significant effective" rate was 32 %. The results showed 18 lipid subclasses and 487 lipid molecules were identified. The change of total lipid volume was not statistically significant (P = 0.088>0.05), but lipid subclass analysis showed the amount of Triglyceride (TG), Phosphatidic Acid (PA), Phosphatidylglycerol (PG) and Lysophosphatidylglycerol (LPG) were significantly increased (P < 0.05). There were 55 kinds of lipid molecules with significant difference after treatment (P < 0.05), and 51 of them belong to TG. The analysis of chain saturation of TG showed that the quantity of TG with 0, 1 and 2 unsaturated bonds increased significantly (P < 0.05). CONCLUSIONS: IPL treatment does not have a significant effect on the overall amount of lipids while the amount of TG, PA, PG, LPG were significantly increased. These lipid changes may potentially improve the skin barrier function, but more high-quality and comprehensive studies are still needed. BULLET POINT: Lipidomics analysis based on LC-MS; Changes of skin surface lipid after IPL treatment; the relationships between skin surface lipid and skin barrier functions. 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 role of epidermal growth factor-containing topical products on recovery and post-inflammatory hyperpigmentation prevention after laser surgeries: A systematic review and meta-analysis.

BACKGROUND: Post-inflammatory hyperpigmentation (PIH) is a common complication after laser surgeries. Recent studies applied epidermal growth factor (EGF) on the lasered area after laser surgery to decrease the incidence of PIH with controversial results. Therefore, a comprehensive literature review of randomized controlled trials (RCTs) was conducted to investigate the issue. METHODS: Two reviewers independently searched the literatures, extracted, and analyzed the data. A total of seven RCTs involving 169 patients were included to evaluate the efficacy of EGF on recovery and PIH prevention after laser surgery. RESULTS: The results show that the incidence of PIH in the EGF group was relatively lower than that in the control group, although the difference was not statistically significant (OR 0.64, 95% CI 0.33 ~ 1.25, p = 0.19). However, the EGF groups had a significant decrease in melanin index (MI) scores at the 1st month after the laser surgery when compared to the control groups (SMD -1.57, 95% CI -2.83 ~ -0.31, p = 0.01). In addition, the patients on the EGF side rated significantly higher satisfactory scores (SMD 0.49, 95% CI 0.22 ~ 0.76, p = 0.0004). There was no significant difference as regard to changes in MI at the 2nd week and 2nd month, erythema index (EI), and trans-epidermal water loss (TEWL) at days 3 and 7 after laser therapy, respectively. CONCLUSION: The current meta-analysis found a limited temporary inhibitory effect of EGF-containing topical products on PIH with no significant effect on reducing post-laser erythema or promoting epidermal barrier repair. More studies are needed in the future due to the small sample size and marked intergroup heterogeneities.

Reflectance Confocal Microscopy of Adult Periorificial Dermatitis: A Case Report.

Periorificial dermatitis (PD) is an inflammatory disorder of the facial skin that mainly occurs around the mouth and manifests as erythema, papules, pustules, scales and other lesions. Special attention is needed in the clinical diagnosis of PD to distinguish it from acne, seborrheic dermatitis (SD), granulomatous rosacea (GR), sarcoidosis and childhood granulomatous periorificial dermatitis (CGPD). We used reflectance confocal microscopy (RCM) images of a patient with PD to assist in the diagnosis of PD. RCM of PD showed slight oedema of the spinous layer. Numerous dendritic cells, scattered hair follicular keratotic plugging and hair follicle dilatation were observed. The dilation and congestion of superficial dermis blood vessels, an increasing vascular density and accelerated blood flow, and a greater abundance of infiltrated inflammatory cells were also detected.

Efficacy and safety of intense pulsed light for the treatment of facial erythema: a systematic review and meta-analysis.

INTRODUCTION: Facial erythema can be seen in many patients. Despite various clinical trials exploring the effect of intense pulsed light (IPL) in treating facial erythema, comprehensive evidence about the specific outcomes remains lacking. EVIDENCE ACQUISITION: We searched published studies in the Web of Science, PubMed, Embase, and Cochrane Library databases based on established inclusion criteria. We calculated odds ratios (OR) to evaluate the effectiveness of IPL in patients with facial erythema. We used Review Manager 5.4.1 software for statistical data analyses with a 95% confidence interval (CI). EVIDENCE SYNTHESIS: This review includes seven studies with 219 patients, of which five compared the efficacy of IPL with pulsed dye laser (PDL). IPL significantly improved facial erythema compared to no treatment (OR=56.64, 95% CI: 22.70-141.33; P<0.00001). However, there was no significant difference between IPL and PDL treatment (OR=1.00, 95% CI: 0.31-3.22; P=1.00). Moreover, there was no significant difference in patients with a >50% reduction in telangiectasias between IPL and PDL treatment (OR=1.00, 95% CI: 0.39-2.56; P=1.00). Furthermore, IPL therapy had no apparent adverse effects for most people besides transitory edema and erythema. CONCLUSIONS: Our meta-analysis indicated that IPL could effectively and safely improve facial erythema with similar efficacy to PDL. Based on its comprehensive function, light side effects, and long curative effect, IPL appears to be a good alternative for treating facial erythema. However, further prospective and high-quality studies are required.

Efficacy and safety of picosecond laser for the treatment of melasma: a systematic review and meta-analysis.

Multiple laser modalities have been used for melasma treatment. However, the effectiveness of picosecond laser in treating melasma remains unclear. This meta-analysis investigated the effectiveness and safety of picosecond laser for melasma treatment. Randomized controlled trials (RCTs) comparing picosecond laser with conventional treatment for melasma were searched through five databases. The melasma area severity index (MASI)/modified MASI (mMASI) was used to quantify the degree of melasma improvement. Standardized mean differences and 95% confidence intervals were calculated using Review Manager for result standardization. Six RCTs, which used picosecond laser at 1064, 755, 595, and 532 nm wavelengths, were included herein. Picosecond laser significantly reduced the MASI/mMASI, but the results were highly heterogeneous (P = 0.008, I2 = 70%). In the subgroup analysis of 1064 and 755 nm picosecond lasers, 1064 nm picosecond laser significantly reduced the MASI/mMASI with no significant side effects (P = 0.04). Meanwhile, 755 nm picosecond laser did not significantly improve the MASI/mMASI compared with topical hypopigmentation agents (P = 0.08) and caused post-inflammatory hyperpigmentation. Other laser wavelengths could not be used in the subgroup analysis owing to an insufficient sample size. Picosecond laser at 1064 nm is safe and effective for melasma treatment. Picosecond laser at 755 nm is not superior to topical hypopigmentation agents in treating melasma. The exact efficacy of other wavelengths of picosecond laser for melasma treatment remains to be verified in large-scale RCTs.

The Efficacy of Fractional Carbon Dioxide Laser in Surgical Scars Treatment: A system Review and Meta-analysis.

BACKGROUND: Surgical scars seriously affect a patient's quality of life, and they have a strong impact on individuals. Many studies have reported the results of using fractional carbon dioxide (CO2) laser to treat surgical scars and have generally found it to be effective. OBJECTIVES: We conducted a meta-analysis with the objective of evaluating and proving the efficacy of fractional CO2 laser therapy for surgical scars. METHODS: We performed a search of databases including PubMed, Web of Science, Embase and the Cochrane Library. The outcomes of the meta-analysis were overall scores on the Vancouver Scar Scale (VSS) and its four dimensions (pigmentation, vascularity, pliability and height). Statistical analysis was performed using RevMan 5.4 software. RESULTS: A total of ten studies were included in this meta-analysis, including six randomized controlled trials (RCTs) and four nonrandomized controlled trials (N-RCTs). In the meta-analysis of RCTs and N-RCTs, similar results were obtained, and fractional CO2 laser irradiation significantly decreased VSS scores (P < 0.00001). In addition, fractional CO2 laser irradiation also had a significant effect on scores on the pigmentation (P = 0.08), vascularity (P = 0.001), flexibility (P = 0.005) and height (P = 0.008) dimensions. Except for mild pain during treatment and temporary erythema after treatment, most patients had no obvious adverse reactions. CONCLUSION: Our study found that fractional CO2 laser exhibits excellent efficacy and safety in terms of surgical scar treatment. Thus, we hope it becomes more widely available to patients with surgical scars. LEVEL OF EVIDENCE III: 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 .

Efficacy and safety of laser-assisted delivery of tranexamic acid for the treatment of melasma: a systematic review and meta­analysis.

Laser-assisted drug delivery (LADD) is a new treatment for delivering drugs within the skin. This meta-analysis investigates the effectiveness and safety of the laser-assisted delivery of tranexamic acid (TXA) to treat melasma. A literature review was conducted by searching publication platforms to search for randomized controlled trials (RCTs) that compared laser-assisted delivery of TXA with laser-alone or topical TXA-alone treatment. The Embase, Web of Science, PubMed, Google Scholar, and Cochrane Library databases were searched, and Melasma Area Severity Index (MASI)/modified MASI (mMASI) scores used as the clinical improvement outcomes. All statistical analyses were performed using the RevMan software (Review Manager, V.5.3). The standardized mean differences and 95% confidence intervals were used to assess the results. Five RCTs were included in this meta-analysis. These studies used ablative fractional photothermolysis and nonablative dermal remodeling laser modalities. The results showed that both laser modalities combined with TXA significantly decreased the MASI/mMASI scores (P = .0003). Furthermore, no serious adverse events were observed, except mild erythema and burning pain. The meta-analysis found that the laser-assisted delivery of TXA is a new effective and safe treatment option for melasma treatment.

Intense pulsed light treatment for inflammatory skin diseases: a review.

Although intense pulsed light (IPL) has been commonly used in the field of medical cosmetics in recent years, the exact outcomes of IPL in the treatment of inflammatory skin diseases remain unclear. To assess the clinical evidence for the use of IPL in the treatment of various inflammatory skin diseases and propose evidence-based recommendations, we searched for relevant publications in the PubMed and Web of Science databases and provided updated information. The inflammatory skin diseases treated with IPL consisted of acne vulgaris, rosacea, psoriasis, hidradenitis suppurativa (HS), atopic dermatitis (AD), Riehl's melanosis, lupus erythematosus, cutaneous sarcoidosis, pilonidal cysts, and pigmented actinic lichen planus (PALP). The efficacy of IPL treatment for these inflammatory skin diseases was described and evaluated. Forty-two studies were included to provide this assessment. The evidence suggests that IPL can effectively and safely improve acne vulgaris and rosacea (recommendation grade B). For other described inflammatory skin diseases, IPL can be used as a tentative or supplementary treatment (recommendation grade C and D). The main complications include transitory erythema, edema, and pain, with the possibility of hyperpigmentation, blisters, and a burning sensation in some individuals.

Efficacy of photodynamic therapy for warts induced by human papilloma virus infection: A systematic review and meta-analysis.

BACKGROUND: The incidence of warts caused by human papilloma virus (HPV) infection is very high in the population. Photodynamic therapy (PDT), as an emerging method for wart treatment, has been demonstrated to be effective and safe by an increasing number of studies. This meta-analysis of previous literature aimed to investigate the potential of PDT as a first-line treatment for warts. METHODS: To acquire proper and accurate information from relevant literature, the four databases PubMed, Embase, Web of Science and the Cochrane Library were searched. The wart clearance rate and patient cure rate were analysed as the primary outcomes. The recurrence rate, patient satisfaction and adverse reactions were also recorded. RESULTS: A total of 19 randomized controlled trials (RCTs) were included based on our search strategy. In the hand and foot wart group, PDT showed a statistically significant improvement in the wart clearance rate compared with placebo (P = 0.02), other lasers (P < 0.0001), and cryotherapy (P < 0.009). PDT use in the condyloma acuminatum group was not superior in terms of the wart clearance rate, with a value lower than that of the carbon dioxide (CO2) laser (P = 0.003) and electrosurgical generator (P < 0.00001). However, all studies mentioned a significant decrease in the recurrence rate after PDT. In the plane wart group, PDT demonstrated its superiority over placebo (P = 0.003) and cryotherapy (P = 0.007) in terms of the cure rate. CONCLUSION: Our study demonstrated that PDT provided several benefits, including but not limited to positive clinical outcomes, low recurrence rates and minor adverse reactions. The use of PDT as first-line therapy can be recommended.

Evaluating the quality of life among melasma patients using the MELASQoL scale: A systematic review and meta-analysis.

BACKGROUND: According to the literature, pigmentary disorders have a significantly negative impact on a person's health-related quality of life. Moreover, among pigmentary disorders, incidence of melasma ranks high. The Melasma Area and Severity Index (MASI) is the scale that is generally used to evaluate a melasma-affected area and its severity. However, the relationship between the MASI and Melasma Quality of Life (MELASQoL) scores, as well as the impact of melasma on patients' quality of life, remain unclear. OBJECTIVES: To explore the influence of melasma on patients' lives, analyze the relationship between the MASI and MELASQoL scores, and identify the factors that may be influencing the quality of life of patients with melasma. METHODS: Two reviewers independently searched four databases (PubMed, Embase, the Cochrane Library, and Web of Science) for literature on quality of life of patients with melasma. In addition to an epidemiological study, a cross-sectional study, and validation studies, gray literature was also included. StataSE version 16 software was used for the meta-analysis. The score of each item on the MELASQoL scale was determined using a random-effects model. RESULTS: Fourteen studies with a total of 1398 melasma patients were included in the systematic review, four of which were eligible for meta-analysis. The relationship between the MELASQoL and MASI scores was found to be mixed. Five studies concluded that the MASI and MELASQoL scores were statistically correlated, while seven studies found no statistical correlation between the two. It is obvious that melasma causes emotional distress and has a negative impact on patients' social lives. Patients were most bothered by the appearance of their skin condition. However, the MELASQoL score had no definite correlation with patient characteristics such as age, education levels, and history. CONCLUSION: Melasma has a significant negative impact on patients' quality of life. Thus, evaluating the quality of life of patients with melasma should not be ignored. Additionally, utilization of the MELASQoL scale should be considered in the care plan. Further studies with larger sample sizes are needed to confirm the relationship between melasma and quality of life.

Efficacy and safety of pulsed dye laser for the treatment of surgical scars: a systematic review and meta-analysis.

Various clinical trials have explored whether the pulsed dye laser (PDL) method is safe to treat scars, especially surgical scars. However, comprehensive evidence confirming the exact outcomes of PDL for treating surgical scars is lacking. The efficacy and safety of PDL in the treatment of surgical scars were determined through a review of several studies. The PubMed, Embase, Cochrane Library, and Web of Science databases were searched, and the main clinical outcomes were Vancouver Scar Scale (VSS) scores in terms of pigmentation, vascularity, pliability, and height. Review Manager 5.4 software was used for statistical analyses of the data; we chose a standardized mean difference (SMZ) to present the results with 95% confidence interval (CI). Overall, seven randomized controlled trials were used for this meta-analysis, all of these papers used 585 nm or 595 nm PDL with 7 mm or 10 mm spot size and a fluence of 3.5 to 10 J/cm2 for treating surgical scars; besides, the pulse duration ranged from 450 µs to 10 ms. We found that PDL significantly resulted in decreased VSS scores (P = 0.02) in four aspects: pigmentation (P = 0.0002), vascularity (P < 0.00001), pliability (P = 0.0002), and height (P = 0.0002). Moreover, scar improvement was similar when using 585 nm and 595 nm PDL in terms of pigmentation (P = 0.76), vascularity (P = 0.34), pliability (P = 0.64), and height (P = 0.57). Furthermore, our review indicated that PDL has no obvious adverse effects for most people, except transitory erythema and purpura. The meta-analysis showed that both 585 nm and 595 nm PDL therapy can effectively reduce the VSS score, suggesting that PDL can be a safe and effective method for the treatment of surgical scars.

Risk of metabolic syndrome in patients with lichen planus: A systematic review and meta-analysis.

BACKGROUND: Studies have investigated whether patients with lichen planus are at a high risk of metabolic syndrome; however, currently, no conclusive data are available in this regard. OBJECTIVE: This meta-analysis was performed to analyze the published literature investigating the association between metabolic syndrome and lichen planus. METHOD: Two reviewers independently searched 4 databases (PubMed, Embase, the Cochrane Library and Web of Science) for observational studies assessing the prevalence of metabolic syndrome in patients with lichen planus. Review Manager 5.3 software was used to statistically analyze the data. RESULTS: 200 relevant articles were searched. After a further reading, 12 studies with 1422 participants (715 with LP and 707 controls) fulfilled the eligibility criteria. Overall, the pooled odds ratio based on random effects analysis was 2.81 (95% confidence interval: 1.79-4.41, P<0.00001). This meta-analysis shows that compared with the general population, patients with lichen planus are more likely to develop metabolic syndrome. Subgroup analysis of prevalence of metabolic syndrome showed higher odds ratio in studies using International Diabetes Federation diagnostic criteria (odds ratio 4.65) and the Harmonized criteria (odds ratio 26.62) than studies using National Cholesterol Education Program Adult Treatment Panel III criteria (odds ratio 1.75), and thus might be more appropriate for diagnosing metabolic syndrome. CONCLUSIONS: This meta-analysis shows that compared with the general population, patients with lichen planus are more likely to develop metabolic syndrome. Therefore, early diagnosis and prompt initiation of first-line therapy for metabolic disorders are important in patients with lichen planus.