Mesotherapy for Melasma – An Updated Review

ABSTRACT

Mesotherapy is a popular novel therapeutic modality that delivers intradermal or subcutaneous microinjections of pharmaceutical compounds. Although this novel treatment method is used commonly in aesthetic dermatology, there is little information about the details of injections, efficacy, and side effects of mesotherapy in melasma. In this review, we evaluated the efficacy of various types of anti-pigmentation agents used with mesotherapy in the management of melasma.

INTRODUCTION

Melasma is an acquired disorder of hyperpigmentation of skin, which symmetrically affects the face and causes depression and frustration in patients, which has a worse impact on their psychosocial quality of life. Therapy of melasma appears to be extremely difficult due to its complex, multifactorial and multi-level etiology, treatment resistance, and high relapse rate. Previously, therapeutic management was based on topical treatment, which did not eliminate relapses and exacerbations of the disease.[1]

Mesotherapy is a trending therapeutic armamentarium in the management of skin rejuvenation. Studies have found its efficacy in the management of melasma when used in combination with skin-lightening agents.[2] In this review, we attempted to explore various such agents in the management of melasma.

MATERIAL AND METHOD

We searched Google Scholar, Medline, and PubMed for related articles with keywords “melasma” OR “chloasma” AND “mesotherapy” OR “injection.” Inclusion criteria were articles that evaluated intradermal injection of lightening drugs and published dates between January 2000 and September 2023. Exclusion criteria were articles in languages other than English or non-human studies.

RESULTS

Tranexamic acid (TA)

In a recent metanalysis of 16 trials, the pooled analysis demonstrated that melasma severity scores decreased significantly at 4 weeks, 8 weeks, 12, and 20 weeks following mesotherapy with TXA. For mesotherapy, it is used at a concentration of 4 mg/ml. TA is a synthetic derivative of the amino acid lysine and works by inhibiting UV-induced plasmin activity in keratinocytes. It does so by blocking the binding of plasminogen to keratinocytes, thereby decreasing free arachidonic acid and diminishing the production of prostaglandins, which are known stimulators of tyrosinase activity. Furthermore, plasmin is thought to convert matrix-bound vascular endothelial growth factor (VEGF) into freely diffusible forms, leading to angiogenesis. Therefore, in the treatment of melasma, TA may exert its effect twofold by reducing the production of pro-melanogenic factors and by decreasing erythema and vasculature. Dosing for the treatment of melasma is far lower than when indicated as an anti-fibrinolytic.[3]

Platelet-rich plasma

Mumtaz et al.[4] compared the effectiveness of mesotherapy with TA and platelet-rich plasma (PRP). According to the researchers, PRP showed better results than tranexamic acid (TA) after 4, 12, and 14 weeks. Additionally, Sarkar and Gupta, in a systematic review, presented mesotherapy with PRP as an effective agent in the treatment of melasma, inhibiting melanin synthesis in a multi-level and multi-directional manner. According to the researchers, growth factors present in PRP, e.g. TGF-β, reduce the amount of tyrosinase and TRP and also have a positive effect on collagen synthesis, skin quality, and texture, as well as reverse photoaging processes.[5]

Vitamin C

Mesotherapy has been shown to be effective in the treatment of melasma. Vitamin C formulations are widely used in mesotherapy; however, no study has evaluated the safety and efficacy of vitamin C in the treatment of melasma. It is also believed to have depigmenting properties via its ability to chelate copper ions used in cellular enzymatic steps required for pigmentation. It is a hydrophilic and unstable molecule, hence has poor penetration into the skin due to the hydrophobic character of the stratum corneum. Vitamin C is also a charged molecule, which further limits the penetration. Till date, only the topical form of vitamin C has been evaluated in the treatment of melasma.[6]

Glutathione

A split face study using a combination of (4 mg/mL TA, 3% vitamin C, and 2% glutathione) on one half, and (4 mg/ml of TA, and 3% Vitamin C) on the other half was carrried out. The authors reported that mesotherapy with combination of TA, vitamin C, and glutathione was associated with better treatment outcome. Glutathione as the other depigmentation agent has been used recently. Hypotheses about depigmentatory effects of glutathione include direct melanocyte tyrosine kinase inactivation, acting in intermediation of altering eumelanin production to pheomelanin production, elimination of free radicals playing role in melanocyte tyrosine kinase production, and regulation of melanotoxic depigmentation factors.[7]

Biological agents

Topical biological agents used with microneedling (MN) include acellular extracted growth factors, adipose-derived stem cells, cultured or extracted bone marrow–derived mesenchymal cells, and conditioned media (CM) from cultured adipose mesenchymal cells (ADSC-CM) and human embryonic stem cell–derived endothelial precursor cell-conditioned medium. None are FDA approved for this purpose, due to the difficulty in measuring efficacy of these treatments – including the differences in the manufacturing and processing of these biological proteins, which affect the efficacy. Currently, no published studies address the potential toxicity of these topical agents applied to skin treated with either MN or thermal needling. Stem cells produce and secrete various cytokines, such as vascular endothelial growth factor (VEGF), hepatocyte growth factor, and transforming growth factor (TGF). TGFβ acts as an antagonist to melanocytic differentiation and could be responsible for the hypopigmentary effects, while TGFβ1 inhibits melanin synthesis by downregulating the expression of tyrosinase and TRP1.[8]

CONCLUSION

Mesotherapy appears to be an effective modality for pigmentation problems, especially in patients of colour. It can be used alone or as a drug-delivery mechanism for depigmenting agents, PRP, or other biological substances. Even though there are no available evidence-base treatment protocols, mesotherapy auspiciously gives favourable results for the treatment of hyperpigmentation disorders.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.