Journal of Cutaneous and Aesthetic Surgery
Print this page
Email this page
Small font size
Default font size
Increase font size
Home About us Current issue Archives Instructions Submission Subscribe Editorial Board Partners Contact e-Alerts Login 


 
   Table of Contents     
ORIGINAL ARTICLES  
Year : 2021  |  Volume : 14  |  Issue : 2  |  Page : 156-159
A pilot study to compare therapeutic efficacy and safety of combined treatment of skin microneedling and depigmenting cream versus depigmenting cream alone in facial melasma at tertiary care center


Department of Dermatology, Venereology, and Leprosy, Surat Municipal Institute of Medical Education and Research (SMIMER), Surat, Gujarat, India

Click here for correspondence address and email

Date of Web Publication10-Aug-2021
 

   Abstract 

Background: Melasma is a commonly acquired, chronic, and relapsing disorder that results in symmetrical, brownish facial pigmentation. It is more common in women than in men, which generally starts between 20 and 40 years of age, and it can lead to considerable embarrassment and distress. Managing melasma is a difficult challenge that requires long-term treatment with a number of topical agents. Microneedling has been described as a new technique to enhance the drug’s transdermal penetration, and has also been reported to result in sustained long-term improvement of recalcitrant melasma. Aim: The aim of this article was to compare the therapeutic efficacy and safety of combined treatment of skin microneedling and depigmenting cream versus depigmenting cream alone in the treatment of melasma. Materials and Methods: A prospective study was conducted with a sample size of 40 patients, with twenty in each of the treatment arms; 20 patients were treated with combined skin needling and depigmenting cream and 20 with depigmenting cream alone. The outcome was evaluated periodically for up to 2 months using the modified Melasma Area and Severity Index (MASI) score. Results: Significant reduction was observed in modified MASI score in the combined treatment, with P value <0.05. Conclusion: Combining microneedling with Kligman’s regimen gives better results in melasma treatment compared to topical treatment alone.

Keywords: Dermaroller, melasma, modified Kligman’s regimen, modified Melasma Area and, Severity, Index

How to cite this article:
Bosamiya SS, Jain SM. A pilot study to compare therapeutic efficacy and safety of combined treatment of skin microneedling and depigmenting cream versus depigmenting cream alone in facial melasma at tertiary care center. J Cutan Aesthet Surg 2021;14:156-9

How to cite this URL:
Bosamiya SS, Jain SM. A pilot study to compare therapeutic efficacy and safety of combined treatment of skin microneedling and depigmenting cream versus depigmenting cream alone in facial melasma at tertiary care center. J Cutan Aesthet Surg [serial online] 2021 [cited 2022 Jan 17];14:156-9. Available from: https://www.jcasonline.com/text.asp?2021/14/2/156/323550





   Introduction Top


Melasma is a commonly acquired condition of hypermelanosis, occurring most commonly on the face. This disorder, which is more prevalent in females and darker skin types, is predominantly attributed to ultraviolet (UV) exposure and hormonal influences.[1] Melasma is generally a clinical diagnosis consisting of symmetric hypermelanosis in three predominant facial patterns: centrofacial, malar, and mandibular. On the basis of histopathologic findings, three variants of melasma are identified: epidermal melasma, when the pigment is deposited in the basal and suprabasal layer; dermal melasma, when melanophages filled with melanin are found in the superficial and middle dermis; and mixed melasma, when findings of the two previous types of melasma are present.

Different treatment modalities, such as topical depigmenting agents, chemical peels, dermabrasion, and laser therapies, have been used in different studies with varying but not so satisfactory outcomes.[2]

Microneedling is minimally invasive procedure. It uses short fine needles to puncture the skin, thereby enhance the transdermal penetration of topical drugs and also stimulates fibroblast proliferation, collagen production and release of growth factors.[3]

The aim of our study was to compare the therapeutic efficacy and safety of combined treatment of skin microneedling and depigmenting cream versus depigmenting cream alone in the treatment of melasma.


   Materials And Methods Top


After approval of institutional ethics committee, a comparative study with a sample size of 40, 20 in each of the treatment arms, was carried out at a tertiary care center in the department of dermatology, venereology, and leprosy from January 2019 to May 2019.

Adult males and females between 18 and 50 years of age with moderate-to-severe bilaterally symmetrical distribution of melasma were included in the study after obtaining written informed consent.

Pregnant/lactating women, patients on hormone replacement therapy or oral contraceptives, history of bleeding disorders, concomitant use of anticoagulants, associated medical illnesses, and history of any other depigmenting treatment in the past 1 month were excluded from the study.

Patients were clinically diagnosed with melasma and had the examination performed by Wood’s light to know the type of melasma.

In Group A, 20 patients were subjected with microneedling. Topical anesthesia was applied for 45 min before the intervention. An instrument (dermaroller) with needle length of 1.5 mm was used. The treatment was proceeded with back and forth movements, approximately 10 times in four directions, drawing four bands that overlapped, resulting in a diffuse erythema and discrete punctuated bleeding. Patients were instructed to use daily the topical sunscreen and depigmentating cream (0.05% tretinoin + 2% hydroquinone + 0.01% floucinolone acetonide) at night. The same procedure was carried out for 30 days after the first treatment.

In Group B, 20 patients were subjected to daily topical sunscreen and depigmenting cream (0.05% tretinoin + 2% hydroquinone + 0.01% floucinolone acetonide) at night.

Photographic documentation was performed by the same investigator and with the same digital camera immediately before the procedure and after 7 days, 1 month, and 2 months.

Both the groups were assessed at baseline and after 7, 30, and 60 days. Data of all the patients were noted in Excel sheet, and were analyzed using STATA software, version 14.2 (StataCorp LLC, TX, USA). Chi-square test was used for categorical variable, and the Wilcoxon signed-rank test was used to compare the mean values of Melasma Area and Severity Index (MASI) scores.


   Results Top


Of the 20 patients in Group A, 16 were female and 4 were male, and the same distribution was present in Group B. The distribution of age group, type of melasma, and types of Fitzpatrick in both the groups are summarized in [Table 1]. There was no significant difference between the groups in terms of age distribution, gender, and type of melasma as P value by chi-square test was >0.05.
Table 1: Demographic profile of patients

Click here to view


After each session of microneedling, mild erythema and edema were noticed but gradually it got subsided in 2–3 days. No other significant side effects were noted.

In both the groups, significant decrease was noted in modified MASI score (P < 0.05) [Figure 1] and [Figure 2].
Figure 1: (A) Group A at baseline. (B) Group A at 1 month. (C) Group A at 2 month

Click here to view
Figure 2: (A) Group B at baseline. (B) Group B at 1 month. (C) Group B at 2 month

Click here to view


When we compared both the groups, more significant and rapid reduction was observed in modified MASI score in Group A (P < 0.05) [Table 2].
Table 2: Mean MASI score

Click here to view


After two sessions of microneedling, improvement of melasma was perceived in all patients of Group A; in addition, there was a subjective report of overall facial skin smoothness and greater radiance by the participants.


   Discussion Top


Microneedling with dermaroller is a new treatment modality for the treatment of scars, especially acne scars, stretch marks, wrinkles, and for facial rejuvenation. It is a simple and relatively cheap modality that can also be used for transdermal drug delivery.[4]

Microneedle technology offers a minimally invasive and painless route of drug delivery.[5] This technology involves the creation of channels in the skin with micron-sized dimensions, thereby enabling the delivery of a broad range of therapeutic molecules including proteins, which would not otherwise cross the intact skin.

Microneedling stimulates fibroblast proliferation, collagen production and release of growth factors, thereby induce beneficial wound-healing response with fewer side effects compared to conventional resurfacing procedures[3]

As it promotes fibroblast proliferation and upper dermal collagenesis, microneedling can restore upper dermal and basal membrane damage in melasma, disfavoring the contact of melanocytes with dermal-released melanogenic stimuli such as endothelin, stem cell factor, and hepatocyte growth factor. In addition, a thickened epidermis can promote additional protection against UV damage.

Long-term improvement of recalcitrant melasma after microneedling was reported in one case series, in which they concluded that microneedling alone, with 1.5-mm needle length, without the addition of any active medication, can cause lightening of skin stains in patients with recalcitrant melasma.[6]

Gentle dermabrasion with dental motor roller provided persistent clearance of melasma in 97% of 410 patients in a Thailand case series,[7] in which they concluded that mechanical dermabrasion is a relatively safe and highly effective means for curing melasma.

In our study, after a period of 7 and 60 days of treatment mean MASI score was reduced significantly in both the groups. When comparison was done between both the groups, the decrease in mean MASI was statistically significant in combined regime as compared to Kligman’s regime alone. This was comparable to the pilot study conducted by Lima et al.[8]

The additional effects of microneedling were suggested in a randomized controlled study with 60 patients comparing intradermal tranexamic acid versus its delivery by microneedling in facial melasma.[9]

Microneedling with vitamin C has also resulted in a better clinical response, followed by Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) for facial melasma, in a split-face trial with 16 patients.[10]

Moreover, several other studies[3],[11] also showed that adjuvant microneedling had led to significant improvement in MASI scores in melasma.


   Conclusion Top


Our study concluded that there was a significant improvement in melasma through microneedling as an adjuvant therapy, and the effect was rapid than the topical depigmenting cream alone in improving melasma. Thus, microneedles appear to be a promising therapeutic method for melasma.

Limitation of our study was small sample size and short-term follow-up. Hence, further randomized controlled studies are warranted to investigate the treatment regimen of microneedling to maximize its efficacy, as long-term maintenance of the results.

However, our study opens new perspectives for the use of this device to enhance the penetration of depigmenting compounds and to reduce treatment times.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Guinot C, Cheffai S, Latreille J, Dhaoui MA, Youssef S, Jaber K, et al. Aggravating factors for melasma: a prospective study in 197 Tunisian patients. J Eur Acad Dermatol Venereol 2010;24:1060-9.  Back to cited text no. 1
    
2.
Gupta AK, Gover MD, Nouri K, Taylor S. The treatment of melasma: a review of clinical trials. J Am Acad Dermatol 2006;55:1048-65.  Back to cited text no. 2
    
3.
Hou A, Cohen B, Haimovic A, Elbuluk N. Microneedling: a comprehensive review. Dermatol Surg 2017;43:321-39.  Back to cited text no. 3
    
4.
Doddaballapur S. Microneedling with dermaroller. J Cutan Aesthet Surg 2009;2:110-1.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Kaushik S, Hord AH, Denson DD, McAllister DV, Smitra S, Allen MG, et al. Lack of pain associated with microfabricated microneedles. Anesth Analg 2001;92:502-4.  Back to cited text no. 5
    
6.
Lima E. Microneedling in facial recalcitrant melasma: report of a series of 22 cases. An Bras Dermatol 2015;90:919-21.  Back to cited text no. 6
    
7.
Kunachak S, Leelaudomlipi P, Wongwaisayawan S. Dermabrasion: a curative treatment for melasma. Aesthetic Plast Surg 2001;25:114-7.  Back to cited text no. 7
    
8.
Lima EVA, Lima MMDA, Paixão MP, Miot HA. Assessment of the effects of skin microneedling as adjuvant therapy for facial melasma: a pilot study. BMC Dermatol 2017;17:14.  Back to cited text no. 8
    
9.
Budamakuntla L, Loganathan E, Suresh DH, Shanmugam S, Suryanarayan S, Dongare A, et al. A randomised, open-label, comparative study of tranexamic acid microinjections and tranexamic acid with microneedling in patients with melasma. J Cutan Aesthet Surg 2013;6:139-43.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Ustuner P, Balevi A, Ozdemir M. A split-face, investigator-blinded comparative study on the efficacy and safety of Q-switched Nd:YAG laser plus microneedling with vitamin C versus Q-switched Nd:YAG laser for the treatment of recalcitrant melasma. J Cosmet Laser Ther 2017;19:383-90.  Back to cited text no. 10
    
11.
Cohen BE, Elbuluk N. Microneedling in skin of color: A review of uses and efficacy. J Am Acad Dermatol 2016;74:348-55.  Back to cited text no. 11
    

Top
Correspondence Address:
Sonal M Jain
Department of Dermatology, Venereology, and Leprosy, Surat Municipal Institute of Medical Education and Research (SMIMER), Umarwada, Surat 395010, Gujarat.
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCAS.JCAS_182_19

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
    Materials And Me...
   Results
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed744    
    Printed24    
    Emailed0    
    PDF Downloaded88    
    Comments [Add]    

Recommend this journal