Factors Associated With Quality of Life and Treatment Practice Among Melasma Patients in Nepal

Introduction: Melasma is a common hyperpigmented disorder of skin which has severe impact on the quality of life. Many modalities of treatment are available to treat melasma. Among them chemical peeling is one of the most popular and widely used method of treatment for melasma.
 Objective: The present study was aimed to assess the efficacy of 30% trichloroacetic acid versus 35% glycolic acid peel in the treatment of melasma.
 Materials and Methods: The prospective randomized study included 50 patients of melasma of both sexes, in 20-55 years age group. Patients were randomly divided into two equal groups A and B. Group A was treated with trichloroacetic acid (TCA 30%) peel and group B with glycolic acid (GA 35%) peel. Five peels were done serially at intervals of 21 days. Patients were followed up every 3 weekly for 6 weeks after the last peel. The disease severity was monitored with digital photography and melasma area and severity index (MASI) score which were calculated at baseline, 6 weeks, 12 weeks and 18 weeks. A visual analog scale (VAS) was calculated at baseline, 12 weeks and 18 weeks.
 Results: Glycolic acid showed better response compared to trichloroacetic acid at the end of five peels, but this difference was not statistically significant (p>0.05). Chemical peeling with trichloroacetic acid produced significantly more erythema, burning sensation (p<0.05) and higher incidence of post peel inflammatory hyperpigmentation (p< 0.05) compared to glycolic acid.
 Journal of Armed Forces Medical College Bangladesh Vol.12(1) 2016: 68-71

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. 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. 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. 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. 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.

BackgroundAccording 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.ObjectivesTo 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.MethodsTwo 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.ResultsFourteen 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.ConclusionMelasma 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.

Background: Although low-fluence 1064-nm Q-switched Nd:YAG laser (QSNYL) is widely used for the treatment of melasma, multiple treatments are necessary for clinical improvement. Superficial chemical peeling using Jessner’s solution has been used for treatment of melasma conventionally.Objectives: To evaluate the additional therapeutic effect and adverse effects of Jessner’s peel when combined with 1064-nm QSNYL for melasma patients in a double-blind, placebo-controlled design.Methods: Total of 52 patients were included. Patients who received 10 sessions of 1064-nm QSNYL plus chemical peeling with placebo (group A) in a two-week interval and those who received 10 sessions of 1064-nm QSNYL plus chemical peeling with Jessner’s solution (group B) in a two-week interval were analyzed. Responses were evaluated using the Melasma Area and Severity Index (MASI) score, physician’s global assessment (PGA) and subjective self-assessment.Results: At 8 weeks, the mean MASI score decreased from 8.68 ± 4.06 to 8.60 ± 3.88 in group A and from 8.98 ± 3.72 to 7.13 ± 2.57 in group B, showing a significant difference (p < 0.001). But at 20 weeks, there was no significant difference on reduction of MASI, self-assessment and PGA between the two groups. No serious adverse effects were reported with the additional Jessner’s peeling.Conclusion: This study suggests Jessner’s peel is a safe and effective method in the early course of treatment for melasma when combined with low-fluence 1064-nm Q-switched Nd:YAG laser.

Background: Although low-fluence 1,064-nm Q-switched Nd:YAG laser (QSNYL) is widely used for the treatment of melasma, multiple treatments are necessary for clinical improvement. Superficial chemical peeling using Jessner's solution has been used for treatment of melasma conventionally. Objectives: To evaluate the additional therapeutic effect and adverse effects of Jessner's peel when combined with 1,064 nm QSNYL for melasma patients in a double-blind, placebo-controlled design. Methods: Total of 52 patients were included. Patients who received 10 sessions of 1,064 nm QSNYL plus chemical peeling with placebo (Group A) in a two-week intervals and those who received 10 sessions of 1,064 nm QSNYL plus chemical peeling with Jessner's solution (Group B) in a 2-week intervals were analyzed. Responses were evaluated using the Melasma Area and Severity Index (MASI) score, physician's global assessment (PGA) and subjective self-assessment. Results: At 8 weeks, the mean MASI score decreased from 8.68 ± 4.06 to 8.60 ± 3.88 in Group A and from 8.98 ± 3.72 to 7.13 ± 2.57 in Group B, showing a significant difference (p < 0.001). But at 20 weeks, there was no significant difference on reduction of MASI, self-assessment, and PGA between the two groups. No serious adverse effects were reported with the additional Jessner's peeling. Conclusion: This study suggests Jessner's peel is a safe and effective method in the early course of treatment for melasma, when combined with low-fluence 1,064-nm QSNYL.

IntroductionMelasma is a common condition seen in dermatology clinics and is considered to be a multifactorial disease. We designed the present study to: study the factors associated with melasma (including metabolic syndrome (MetS) and biochemical parameters); compare the characteristics of melasma and other factors (MetS and biochemical parameters) in male and female melasma patients; and evaluate the quality of life in melasma patients and its correlation with the severity of the condition. MethodsThis study is a case-control study of 80 individuals with melasma and 80 controls attending a private dermatology clinic in Mumbai, India. We collected demographic details and other risk factors in both groups and clinical details in patients with melasma. We assessed the following biochemical parameters, such as fasting blood sugar, glycated hemoglobin (HbA1c), triglycerides, and high-density lipoproteins. In patients with melasma, severity was evaluated using the Melasma Area and Severity Index (MASI) score, and quality of life using the Melasma Quality of Life (MELASQOL) questionnaire.ResultsThe mean (SD) age of the cases (37.2 (5.9)) was significantly higher than controls (30.6 (7.0)) years (p<0.001). A significantly higher proportion of cases had a family history (in first-degree relatives) compared with controls (52.5% (n=42) vs 16.3% (n=13); p<0.001). A lower proportion of cases were classified as MetS compared with controls; however, it was not statistically significant (30.0% (n=24) vs 33.8% (n=27); p=0.61). Although a higher proportion of females had metabolic syndrome compared with males, the difference was not statistically significant (35.2% (n=19) vs 19.2% (n=5); p=0.15). In multivariate models, melasma was significantly associated with age ≥35 years (odds ratio (OR): 4.3, 95% confidence interval (CI): 1.6, 11.4; p<0.01), being married (OR: 4.8, 95% CI: 1.1, 21.7; p<0.01), and a family history of melasma (OR: 8.1, 95% CI: 2.9, 23.1; p<0.01). Males melasma cases were more likely to have high triglyceride levels compared with females (OR: 8.6, 95% CI: 1.6, 47.5; p=0.014). Correlation between MASI and MELASQOL scores was statistically significant in females (r=0.28; p=0.04), but not in males (r=12; p=0.573).ConclusionsFactors associated with melasma were age ≥35 years, a family history of melasma, and being married. There was no significant difference in those classified as metabolic syndrome between these two groups. In melasma cases, in general, there was no significant difference in demographic and clinical characteristics between males and females. However, males had significantly higher levels of triglycerides compared with females. The association between melasma severity and quality of life was significant only in females.

This study aimed to evaluate the efficacy of amber photobiomodulation (PBM) compared to topical tranexamic acid (TXA) for the treatment of melasma. In a non-inferiority randomized controlled trial, 21 women were randomized to either active PBM with placebo cream (n = 10) or sham PBM with 5% liposomal TXA cream (n = 11) for 12 weeks. A noninferiority study was chosen based on the hypothesis that PBM could offer comparable efficacy to TXA with fewer adverse effects. The primary outcome was the Melasma Area and Severity Index (MASI). Secondary outcomes included corneomelametry, Physician's Global Assessment (PGA), quality of life measured by the MELASQoL questionnaire, and adverse events. No significant differences were observed in the MASI or PGA scores, within or between groups. However, the study was underpowered (51% power) due to early termination and is thus considered a pilot. A transient increase in pigmentation intensity was observed in the TXA groups at week six. Despite the lack of clinical improvement, both groups sustained improvements in quality of life. The adverse events were mild, with PBM associated with warmth and TXA with a burning sensation. The absence of MASI reduction can be attributed to the elevated environmental temperatures during the study period, consistently above historical averages. In addition, both PBM and TXA may have limited efficacy in cases of chronic or dermal melasma. Although no significant clinical changes were detected in MASI or PGA, both treatments improved the quality of life, highlighting the importance of patient-reported outcomes. Given the small sample size and potential environmental confounders-particularly elevated temperatures during the study period-definitive conclusions about treatment efficacy cannot be drawn. Future studies should consider optimized protocols and/or combination therapies. Clinical Trials No. NCT05326997, April 14th 2022.

Background: Melasma is a significant cosmetic concern globally, affecting individuals across various ethnic backgrounds, particularly in South Asian populations. The condition's etiology is complex, involving genetic, hormonal, and environmental factors such as sun exposure. Despite numerous treatment options, melasma remains challenging to manage effectively. Recent studies have explored the efficacy of tranexamic acid and azelaic acid, both of which target the melanin synthesis pathway but through different mechanisms. Objective: The aim of this study was to compare the effectiveness of topical 5% tranexamic acid versus 20% azelaic acid in the treatment of melasma, with a focus on changes in the Melasma Area and Severity Index (MASI) scores. Methods: This prospective comparative study was conducted at the Dermatology department of PIMS Hospital, Pakistan, over six months from August 2023 to January 2024. A total of 200 patients with melasma were enrolled and randomly assigned to two groups: Group A received 5% tranexamic acid cream, and Group B received 20% azelaic acid cream, both applied twice daily. Inclusion criteria included men and women aged 18 to 50 years with a diagnosis of melasma for at least six months. Pregnant women, patients with a history of Systemic Lupus Erythematosus (SLE) or Discoid Lupus Erythematosus (DLE), and those on hormonal therapy were excluded. The primary outcome measure was the change in MASI scores from baseline to the end of the study period. Data were analyzed using SPSS Version 25. Results: The study found significant differences in treatment efficacy between the two groups. Group A (tranexamic acid) showed a reduction in MASI scores from 7.94 ± 1.88 at baseline to 5.50 ± 1.61 post-treatment. Group B (azelaic acid) demonstrated a decrease from 8.21 ± 1.96 to 5.89 ± 1.49. The proportion of patients experiencing excellent response was higher in Group A (36.0%) compared to Group B (19.0%), with a statistically significant difference in overall treatment efficacy (P&lt;0.0001). Conclusion: Topical 5% tranexamic acid was more effective than 20% azelaic acid in improving MASI scores in patients with melasma. This study supports the inclusion of tranexamic acid as a preferable treatment option for melasma, offering a promising alternative for those not responding to conventional therapies.

Background: Quality of life (QoL) is defined as capacity to perform the daily activities appropriate to person’s age and his/her major role in the society. Facial appearance plays an important role in self- perception and interaction with others and severe facial blemishes like melasma leave a deleterious impact on patient’s quality of life. This study aimed to assess Psychosocial impact of melasma among Sudanese females attending Khartoum Dermatology Teaching Hospital, 2020-2021. Methods: This study was an observational cross sectional hospital based study conducted at Khartoum Dermatology and Venereology Teaching Hospital in 2020. The study included 135 melasma patients. In these patients the quality of life was assessed using the melasma quality of life measure (MELASQoL). Furthermore, the patients were evaluated using the melasma area and severity index (MSI). Data collected, were analyzed using SPSS version 25.0. Results: More than half (59.6%) of melasma patients were in age group 20-30 years old and more than half (57.9%) of melasma patients were married. Majority (62.3%) of melasma patients had MASI score of less than 3. There was significant association between age and score, gender and score; hence p value was less than 0.05 (&lt;0.05). Conclusions: Improvement of early detection of impaired quality of life among melasma patients may provide. Effective management and prevention of this complication due to melasma.

Objectives: In this study, the objective was to evaluate the validity and reliability of the Turkish version of the melasma quality of life questionnaire (MelasQoL-Tr) for melasma patients. Methods: The study included 114 melasma patients. The melasma area and severity index (MASI), MelasQoL-Tr and the Turkish short version of the QoL assessment instrument from the World Health Organization (WHOQOL-BREF) were used to assess melasma severity and QoL at baseline. The reliability and validity of MelasQoL-Tr were computed. Results: The mean age of the patients in the study was 31.8 ± 7.3 years. The internal consistency of the scale (Cronbach's alpha coefficient) was 0.88. The MelasQoL-Tr score was 29.9 ± 14.6 (range 10-66). The total WHOQOL-BREF score was 54.8 ± 9.8. The comparison of MelasQoL-Tr and WHOQOL-BREF questionnaires showed an inverse significant correlation on total scores, which indicated a sufficient convergent validity. According to the subscale of WHOQOL-BREF, the inverse correlation was most significant between the MelasQoL-Tr score and psychological domain and less significant between the MelasQoL-Tr score and environmental domain. The MelasQoL-Tr score and MASI were significantly correlated. Conclusion: The Turkish version of the MelasQoL was valid and reliable for evaluating the quality of life of Turkish melasma patients.

Aim: To compare the efficacy and safety of topical 3% tranexamic acid gel vs 35% glycolic acid peel in the treatment of melasma over face.&#x0D; Materials and Methods: This is an open labelled, Randomised Controlled Trial(RCT) conducted on 60 patients. Patients were randomly divided equally into 2 groups – Group A and Group B. Patients of Group A used topical 3% tranexamic acid gel twice a day and Group B patients were treated with 35% glycolic acid peel with a contact period of 5 minutes once in every 2 weeks. Patients were assessed every month for a period of 3 months and recurrence was assessed for the next consecutive 3 months following the treatment. Patients were asked to use a broad spectrum sunscreen before sun exposure during the entire study. Assessment of reduction in pigmentation was made by MASI score, subjective and objective valuation (blind observer) and photographic comparison. Safety profile was assessed by the side effects.&#x0D; Results: The mean value of Melasma Area and Severity Index(MASI) score for glycolic acid group at baseline was 14.41 which reduced to 7.05 at end of 3rd month. In tranexamic acid group, the mean value of MASI score at baseline was 14.58 which reduced to 5.96 at the end of 3rd month. The mean percentage of improvement in MASI score in glycolic acid group 52% whereas in tranexamic acid group it is 61%. The side effects were minimal in this study. Side effects were more in glycolic acid group than tranexamic acid group. A total of 8 patients had recurrence during follow up. In glycolic acid group, 5 patients had recurrence whereas in tranexamic acid group, only 3 patients had recurrence. The percentage of recurrence in glycolic acid group is 16.7 % whereas in glycolic acid group it is 10.7%.&#x0D; Conclusion: Tranexamic acid is a novel emerging therapy for melasma. In this study it has been found that topical 3% tranexamic acid is equally efficacious as 35% glycolic acid peel with minimal side effects in the treatment of melasma.

Melasma is one of the common pigmentary problems affecting females in our community, owing to the frequent use of hormonal contraceptives as well as our sunny climate. A lot of treatment options are available but none of them is completely satisfactory. Many patients prefer the use of topical preparations and minimally invasive methods. Tranexamic acid (TA) is a potential treatment option for hyperpigmentation with different delivery routes. We designed the study in order to evaluate the efficacy of TA in melasma using 2 different routes of delivery. A randomised clinical trial was performed on 60 female patients with melasma, they randomly divided into three groups; A, B and C. Group (A) patients received TA (4mg/mL) intradermal injections every 2weeks with, group B received TA (10mg/mL) intradermal injections every 2weeks, group C received TA cream (10% concentration) twice daily, treatment continued for 12weeks in all groups. Melasma Area and Severity Index (MASI) scores were measured for each patient before and after completion of treatment. The percentage of MASI score reduction was highest in group B (62.7%) versus (39.1%) in group A, while the percentage of MASI reduction was the lowest in group C (4.2%). Tranexamic acid is a safe effective and well-tolerated treatment option for melasma patients. Intradermal injection of TA leads to better results than the topical application. Topical TA cream (even in a high concentration) produce fair improvement of melasma.

ABSTRACTBackgroundMelasma is a prevalent skin condition that primarily affects females of reproductive age. Despite the various available treatments, managing melasma is challenging due to frequent relapses and partial responses. Tranexamic acid (TXA) has gained attention as a potential treatment because of its antifibrinolytic and anti‐melanogenic properties. However, there is still limited information on the efficacy of oral versus topical TXA formulations.AimThe present investigation explored the efficacy and safety of topical versus oral TXA in melasma patients to determine whether topical administration could provide a viable alternative with improved tolerability.Patients/MethodsIn this single‐center randomized trial, 50 melasma patients received oral TXA (250 mg twice daily) or topical TXA (a 5% cream applied twice daily) for 12 weeks. Melasma severity was measured using the Melasma Area and Severity Index (MASI) score at baseline and after 3 months. Data analysis was performed using SPSS version 24, with p < 0.05 considered statistically significant.ResultsFifty female patients (mean age≈39.9 years) were equally randomized to the oral and topical TXA group. One patient in the topical group discontinued treatment due to sensitivity, while all in the oral group completed the study. At baseline, MASI scores were not significantly different between the two groups (p = 0.28). After 12 weeks, both groups demonstrated significant reductions in MASI scores (oral group: 58.86%; topical group: 50.88%; p = 0.001 for each), though the difference was insignificant.DiscussionFifty female patients (mean age≈39.9 years) were equally randomized to the oral and topical TXA groups. One patient in the topical group discontinued treatment due to sensitivity, while all in the oral group completed the study. Baseline MASI scores were similar (p = 0.28). After 12 weeks, both groups demonstrated significant reductions in MASI scores (oral group: 58.86%; topical group: 50.88%; p = 0.001 for each), though the difference was not statistically significant.ConclusionBoth forms of TXA are effective with low side effects. The choice between oral and topical TXA can depend on patient preference and convenience.

Introduction. Melasma is a common skin pigmentation disorder affecting a patient’s life psychologically and socially. Topical medications or lasers can have temporary and limited therapeutic effects on melasma. Material and Methods. This study is a prospective clinical trial comparing therapeutic effects of oral Tranexamic acid (TXA) and topical Hydroquinone (HQ) cream. A total number of 69 patients were examined. During the study, 10 patients failed to appear for the follow-up and 59 of them completed the trial. The patients were also divided randomly into two groups. Group A received TXA capsule 250 mg every 12 hours and group B received 4% topical HQ cream day and night. The patients from both groups were treated for 3 months. Melasma Area and Severity Index (MASI) scores were then calculated at the baseline, 4 weeks, and 12 weeks into the treatment and 3 months after the end of intervention. Results. MASI baseline, 4 weeks,12 weeks, and 24 weeks in TXA group were 21.66, 13.69, 9.10, 9.24; respectively. Reduction of MASI between baseline and 4 weeks was statistically significant. Such a decreasing trend in MASI scores between baseline and 12 weeks was also reported as statistically significant (p=0.001). In the HQ group, MASI baseline,4 weeks, 12 weeks, and 24 weeks were 21.46, 13.57, 10.93, 11.20; respectively. Reduction of MASI scores between baseline and 4 weeks was statistically significant. Moreover, a decline in MASI scores was observed between baseline and 12 weeks that was statistically significant (p=0.001). Considering both groups MASI scores were reduced but the difference between two study groups was not statistically significant (p=0.98). Conclusion. The efficacy of TXA and HQ was the same and both could significantly reduce MASI scores.

Introduction: Melasma is a chronic acquired disorder of facial melanosis characterized by brown-black macules on sun exposed areas of face. Melasma has a severe impact on the quality of life (QOL) of the patients, causing emotional, psychological, and social stress.Aims and objectives: (1) To evaluate the impact of melasma on QOL using the Hindi adaptation of Melasma QOL (Hi-MELASQOL). (2) To study the relation between Melasma Area and Severity Index (MASI) score and Hi-MELASQOL.Materials and Methods: A total of 156 patients of melasma attending the dermatology outpatient department of our institute were included. Patients were subjected to assessment of MASI score and Hi-MELASQOL questionnaire consisting of 10 objective questions using a Likert-scale of 1 to 7.Results: Hi-MELASQOL did not correlate statistically with MASI score, age of onset of melasma or with its duration. No statistical significant difference was found among the Hi-MELASQOL scores of patients with different occupation, education levels, or marital status. In Hi-MELASQOL questionnaire, 36.54% cases were bothered due to the appearance of their skin due to melasma, 41.03% felt frustrated, 46.03% felt embarrassed, and 48.72% felt depressed.Conclusion: Impact of melasma as measured by Hi-MELASQOL revealed that patients with melasma felt frustrated, embarrassed, and depressed. Melasma has effect on interpersonal interactions in Indian patients. However, Hi-MELASQOL is independent of MASI score. Hence, QOL should be assessed in every patient of melasma and treatment plan should be devised taking into account the psychosocial and emotional stress.