Topical tranexamic acid, kojic acid, and niacinamide containing regimen plus antioxidants vitamin C and E with single session of Q-switched(QS) laser:
Integrated skincare program of melasma in Asians

Dr. K. Hau

INTRODUCTION

Management of melasma in Asians are complex and challenging. It needs integrated modalities, long term maintenance with consistent lifestyle modification and compliance [1]. Controversies exist on how to combine the existing modes of treatment, like the role of QS/Picosecond(QS/PS) lasers.

Energy-based devices were greatly utilized in current aesthetic practice for various indications through selective photothermolysis and other mechanisms [2]. However, its role in melasma by using QS/PS lasers are limited by inconsistent treatment results, frequent relapses and sideeffects of rebound hyperpigmentation as well as permanent hypopigmentation upon repeated challenge [3].

The pathogenesis of melasma is complex and extends beyond melanocytes and recent literature points to interactions between keratinocytes, mast cells, gene regulation abnormalities, neovascularization, and disruption of basement membrane [4].

This complex pathogenesis makes melasma difficult to target and likely to recur by involving multiple pathologies like solar elastosis, ongoing inflammation, hormones, barrier disruption, oxidative stress, ultraviolet as well as visible light [5].

Managing melasma in the real world particularly in South Asian ethnic groups poses a real challenge by the prevalent number, severity of the disease and the abundance of sunshine[6]. Together with the availability of numerous ineffective and sometimes dangerous over-thecounter remedies and myths that deter a proper care for patients suffering from melasma [7].

Vitamin C & E are potent antioxidants that can salvage the damage from free radicals and ageing effects due to impaired cutaneous scavenging system. These antioxidants protect fibroblasts (via protection of bFGF)and that could be essential in the underlying mechanism of action responsible for recovery. Combination of l-ascorbic acid, alpha tocopherol, and ferulic acid formulation has resulted in decreased edema, reduce erythema and inflammation and promote recovery after laser treatment [8].

One of the great advancement in treatment of melasma is by the use of tranexamic acid. Topical mixture of tranexamic acid, niacinamide, and kojic acid has confirmed the benefit for post-laser treated melasma lesions.On the other hand, the role of laser is yet to be defined, the current data favours low fluences and limited sessions [9].

A structured skincare program, involving coaching and integrating the current arena based on current scientific evidence is yet to be defined.