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Transepidermal delivery of hydroquinone and clobetasol propionate using ablative fractional radiofrequency and ultrasound in the treatment of melasma
3091
2744
New severity assessment method for melasma Jaeyoung Kim, PhD, Research Institute for Skin Image, Seoul, South Korea; Onseok Lee, PhD, Medical IT Engineering, College of Medical Sciences, Soonchunhyang University; Seunghan Ha, PhD, Departments of Nursing, School of Health, Chungbuk Health and Science University, Cheongju, South Korea; Jaewoo Ahn, MD, Departments of Dermatology, Seoul, South Korea; Chilhwan Oh, MD, PhD, Departments of Dermatology, Korea University Medical School, Seoul, South Korea Introduction and objective: Melasma is one of the most common pigmentary skin diseases. It is common patchy brown, tan, or blue-gray facial skin discoloration and typically appears on the upper cheeks, upper lip, forehead, and chin. The most common severity assessment method of melasma is Melasma Area Severity Index (MASI) score. However, the ordinary MASI scoring system has some problems due to the observer’s subjective visual judgment. This study aimed to develop a new advanced severity assessment method of melasma based on computerized optical imaging analysis system. Material and methods: In this study, we propose a new computerized optical imaging analysis method for the quantitative assessing of melasma. In order to quantitative analyze the involvement area, we were divided into frontal, cheek and chin region in patients. After that, the divided images were processed to define the melasma lesions by the multithreshold method and gradient mask were apply to correct the curvature error of facial contour. Degree of darkness and homogenesis were measured based on intensity of gray level and difference of gray level in melasma lesions.
Repigmentation in three cases of perineum vitiligo induced by photodynamic therapy Li Qin, MD, PhD, Department of Dermatology, Wuhan No. 1 Hospital, Wuhan, China
Result: The proposed new quantitative assessment method for melasma is more objective and accurate than ordinary MASI method. In addition, a new assessment method is able to quantify a minute difference of pigmented pattern among melasma patients. Conclusion: We developed the quantitative assessment method for melasma using computerized optical imaging analysis. Based on the results, our new computerized optical imaging system could be used as valuable tools to assess the severity of various pigmentary skin diseases including melasma. Commercial support: None identified.
Vitiligo is an acquired depigmentary disorder of the skin which results from the destruction of melanocytes. The depigmentation in genitalia site has a deleterious effect on the psychosexual function of many individuals. So far, very few data about perineum vitiligo treatment are available. Here, the authors report repigmentation in three cases of perineum vitiligo treated by photodynamic therapy (PDT). In all the patients, 5-aminolevulinic acid of 20% concentration was used after occluded 3 hours, following irradiation with red light (630 nm) with the same parameters (80 mw/cm2, 20 min), one session every two weeks were made. During the treatment with PDT, no other treatments to vitiligo were done. Case 1: A 24-year-old unmarried female reported perineum vitiligo of 4 years, the lesion was nonprogressive for about 3 years. 3 months before PDT treatment, the patients received topical tacrolimus twice daily treatment for 6 months with no beneficial. Physical examination showed that the lesion was 6 cm2. She received 11 sessions and 40% of the lesions repigmented. Case 2: A 20-year-old unmarried female with perineum vitiligo of 2 years, The lesion spread progressively for the first half year and was nonprogressive thereafter. She failed to respond to the medical treatment administrated to her before PDT. Examination revealed total area of the lesion was 30 cm2. She received 12 sessions and 90% of the entire lesion showed good repigmentation 2 weeks after the last treatment. Case 3: A 50-year-old married female of 3 years’ duration, the lesions had been progressive in the first year and spread almost the whole perineum. She was refractory to medical treatments, which she had received earlier. This patient underwent only 2 sessions and break the treatment because of the severe itching occurred after PDT. She received 30% repigmentation of the examination 3 months after the last treatment. During the treatment, the patients suffer mild burning or pain, itching and after the sessions erythema was noted, which were well-tolerated by most patients and generally disappeared several hours after treatments except for the 50-year-old patient with severe itching. This is to our knowledge the first study of PDT in perineum vitiligo. All the three patients yielding repigmentation who were satisfied with the treatment. Further studies with more patients are necessary to determine if PDT is a good option of treatment in perineum vitiligo. Commercial support: None identified.
3875
2354 Progression of idiopathic eruptive macular pigmentation in a girl from the child to adolescence Wen-Chien Tsai, MD, Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College, Taipei, Taiwan; ChihHung Lee, MD, PhD, Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College, Taipei, Taiwan A 14-year-old girl suffered from brownish round macules and patches over face, trunk and proximal limbs since she was 7 years old. She has no underlying medical disease or familial history of pigmentation disorders. The lesions were asymptomatic and there was no preceding redness or inflammation. After 7 years of loss follow up, she came back to our clinic. There were progressions of generalized brownish patches over whole face, chest, back and upper extremities. Physical examination revealed normal development of neurocutaneous system. Blood levels of mercury, lead, arsenic and cadmium were within normal limits. The histopathologic examinations for lesional skin showed increased basal layer pigmentation and increased melanocytic activity by dihydroxyphenylalanine reaction stain. Electron microscopy examination of the lesion skin revealed an increase in numbers and an increase in maturity of melanosomes in both basal and suprabasal keratinocytes. However, the cell number of melanocyte was within normal range. The diagnosis of idiopathic eruptive macular pigmentation (IEMP) was rendered. Oral transamic acid and topical Triluma cream were given, however, no significant responses were noticed during one year of follow up. IEMP is characterized by rounded or ovalshaped, brownish macules without previous erythema or other symptom. The lesions mainly involved neck, chest, back and proximal extremities. Our case presented with an unusual course of aggressive progression and extensive face involvement in the seven years follow-up. The pathogenesis of IEMP remains unclear. Endocrine factors, inflammatory stimuli, and autoimmune phenomenon were hypothesized. Asians and Egyptians were seem to be more vulnerable for IEMP according to reported case numbers. Ethnicity or Fitzpatrick skin type may be considered as risk factors. IEMP generally tends to regress spontaneously in months years without treatment. However, in our case, the disease runs an intractable and progressive course from year 7 to year 14. Similarly, a case of 21 year history of IEMP has been reported before, suggesting that IEMP may not be necessarily selfremitting. Topical steroids, hydroquinone, and tretinoin were not proved to be helpful in most reports. IEMP is a relatively rare disorder and should be considered as differential diagnosis for child or young adults with hyperpigmentation disorders. The management of IEMP may be difficult for extensive and nonremitting cases. Commercial support: None identified.
AB232
J AM ACAD DERMATOL
Transepidermal delivery of hydroquinone and clobetasol propionate using ablative fractional radiofrequency and ultrasound in the treatment of melasma Valeria Campos, MD, University of Jundiai, Jundiai, Brazil; Ana Flavia Salai, MD, Clinica Valeria Campos, Jundiai, Brazil; Natalia Roberta Castellen, MD, Clinica Valeria Campos, Jundiai, Brazil; Fernanda Barbosa, MD, Clinica Valeria, Brazil; Luiza Pitassi, PhD, University of Campinas, Jundiai, Brazil; Daniel Manor, MD, Clinica Valeria Campos, Jundiai, Brazil; Sully Freire Luz, Clinica Valeria Campos, Jundiai, Brazil Background: Melasma is a common disorder of hyperpigmentation that has a significant negative impact on the quality of life in affected individuals and is often difficult to treat. A range of treatments for melasma exist, with varying degrees of efficacy and success. Depigmenting agents have been the gold standard for the treatment of melasma for decades. But, some drugs that are absorbed do not penetrate deeply enough to reach the desired target in the tissue. Fractional ablation penetrates the skin by creating microchannels which reach beyond the stratum corneum, creating a direct path for drugs to reach the deeper skin tissue. Objective: This present study intends to evaluate the clinical efficacy and the safety of the combination of fractional ablative radiofrequency technology paired with an acoustic pressure wave ultrasound technology to topically push the 4% hydroquinone and 0.05% clobetasol propionate through the albeit perforated melasma treated skin. Methods: The study enrolled 20 patients of Fitzpatrick skin types I-IV with refractory facial melasma. Initially, patients were treated every other week, during 3 months (6 treatments) with fractional radiofrequency device (RF Pixel Microplasma) for skin perforation employing 50W and 1 pass, followed by acoustic pressure ultrasound. The treatment settings of the acoustic pressure ultrasound handpiece were 80% of the ultrasound energy output and 50 Hz for the ultrasound sonotrode vibration rate. Immediately 4% hydroquinone and 0.05% clobetasol propionate were applied on the perforated skin surface. Clinical and instrumental evaluations for improvement in pigmentation were conducted at baseline and at each subsequent follow-up visit at 2, 4, 8 and at 12 weeks. The effects of treatment were evaluated by three physicians not involved in the study and by standardized digital photographs (VISIA; Canfield Imaging Systems, USA) based on improvement of pigmentation and reduction in melasma size. Results: This study shows the improvement of melasma through the enhanced penetration of hydroquinone and clobetasol propionate using ablative fractional radiofrequency and ultrasound and acoustic pressure. The image analysis showed that hyperpigmentation was significantly reduced at 2, 4, 6 and 12 weeks after treatment. The therapy was well tolerated, safe and no adverse events were reported during the study. Conclusion: This study has demonstrated the improvement of melasma through the enhanced penetration of hydroquinone and clobetasol propionate by using a paired model for transepidermal drug delivery which could be a safe, tolerable, and effective alternative modality for the treatment of melasma. The RF Pixel Microplasma was lent to the group for this study.
MAY 2016
2744
New severity assessment method for melasma Jaeyoung Kim, PhD, Research Institute for Skin Image, Seoul, South Korea; Onseok Lee, PhD, Medical IT Engineering, College of Medical Sciences, Soonchunhyang University; Seunghan Ha, PhD, Departments of Nursing, School of Health, Chungbuk Health and Science University, Cheongju, South Korea; Jaewoo Ahn, MD, Departments of Dermatology, Seoul, South Korea; Chilhwan Oh, MD, PhD, Departments of Dermatology, Korea University Medical School, Seoul, South Korea Introduction and objective: Melasma is one of the most common pigmentary skin diseases. It is common patchy brown, tan, or blue-gray facial skin discoloration and typically appears on the upper cheeks, upper lip, forehead, and chin. The most common severity assessment method of melasma is Melasma Area Severity Index (MASI) score. However, the ordinary MASI scoring system has some problems due to the observer’s subjective visual judgment. This study aimed to develop a new advanced severity assessment method of melasma based on computerized optical imaging analysis system. Material and methods: In this study, we propose a new computerized optical imaging analysis method for the quantitative assessing of melasma. In order to quantitative analyze the involvement area, we were divided into frontal, cheek and chin region in patients. After that, the divided images were processed to define the melasma lesions by the multithreshold method and gradient mask were apply to correct the curvature error of facial contour. Degree of darkness and homogenesis were measured based on intensity of gray level and difference of gray level in melasma lesions.
Repigmentation in three cases of perineum vitiligo induced by photodynamic therapy Li Qin, MD, PhD, Department of Dermatology, Wuhan No. 1 Hospital, Wuhan, China
Result: The proposed new quantitative assessment method for melasma is more objective and accurate than ordinary MASI method. In addition, a new assessment method is able to quantify a minute difference of pigmented pattern among melasma patients. Conclusion: We developed the quantitative assessment method for melasma using computerized optical imaging analysis. Based on the results, our new computerized optical imaging system could be used as valuable tools to assess the severity of various pigmentary skin diseases including melasma. Commercial support: None identified.
Vitiligo is an acquired depigmentary disorder of the skin which results from the destruction of melanocytes. The depigmentation in genitalia site has a deleterious effect on the psychosexual function of many individuals. So far, very few data about perineum vitiligo treatment are available. Here, the authors report repigmentation in three cases of perineum vitiligo treated by photodynamic therapy (PDT). In all the patients, 5-aminolevulinic acid of 20% concentration was used after occluded 3 hours, following irradiation with red light (630 nm) with the same parameters (80 mw/cm2, 20 min), one session every two weeks were made. During the treatment with PDT, no other treatments to vitiligo were done. Case 1: A 24-year-old unmarried female reported perineum vitiligo of 4 years, the lesion was nonprogressive for about 3 years. 3 months before PDT treatment, the patients received topical tacrolimus twice daily treatment for 6 months with no beneficial. Physical examination showed that the lesion was 6 cm2. She received 11 sessions and 40% of the lesions repigmented. Case 2: A 20-year-old unmarried female with perineum vitiligo of 2 years, The lesion spread progressively for the first half year and was nonprogressive thereafter. She failed to respond to the medical treatment administrated to her before PDT. Examination revealed total area of the lesion was 30 cm2. She received 12 sessions and 90% of the entire lesion showed good repigmentation 2 weeks after the last treatment. Case 3: A 50-year-old married female of 3 years’ duration, the lesions had been progressive in the first year and spread almost the whole perineum. She was refractory to medical treatments, which she had received earlier. This patient underwent only 2 sessions and break the treatment because of the severe itching occurred after PDT. She received 30% repigmentation of the examination 3 months after the last treatment. During the treatment, the patients suffer mild burning or pain, itching and after the sessions erythema was noted, which were well-tolerated by most patients and generally disappeared several hours after treatments except for the 50-year-old patient with severe itching. This is to our knowledge the first study of PDT in perineum vitiligo. All the three patients yielding repigmentation who were satisfied with the treatment. Further studies with more patients are necessary to determine if PDT is a good option of treatment in perineum vitiligo. Commercial support: None identified.
3875
2354 Progression of idiopathic eruptive macular pigmentation in a girl from the child to adolescence Wen-Chien Tsai, MD, Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College, Taipei, Taiwan; ChihHung Lee, MD, PhD, Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College, Taipei, Taiwan A 14-year-old girl suffered from brownish round macules and patches over face, trunk and proximal limbs since she was 7 years old. She has no underlying medical disease or familial history of pigmentation disorders. The lesions were asymptomatic and there was no preceding redness or inflammation. After 7 years of loss follow up, she came back to our clinic. There were progressions of generalized brownish patches over whole face, chest, back and upper extremities. Physical examination revealed normal development of neurocutaneous system. Blood levels of mercury, lead, arsenic and cadmium were within normal limits. The histopathologic examinations for lesional skin showed increased basal layer pigmentation and increased melanocytic activity by dihydroxyphenylalanine reaction stain. Electron microscopy examination of the lesion skin revealed an increase in numbers and an increase in maturity of melanosomes in both basal and suprabasal keratinocytes. However, the cell number of melanocyte was within normal range. The diagnosis of idiopathic eruptive macular pigmentation (IEMP) was rendered. Oral transamic acid and topical Triluma cream were given, however, no significant responses were noticed during one year of follow up. IEMP is characterized by rounded or ovalshaped, brownish macules without previous erythema or other symptom. The lesions mainly involved neck, chest, back and proximal extremities. Our case presented with an unusual course of aggressive progression and extensive face involvement in the seven years follow-up. The pathogenesis of IEMP remains unclear. Endocrine factors, inflammatory stimuli, and autoimmune phenomenon were hypothesized. Asians and Egyptians were seem to be more vulnerable for IEMP according to reported case numbers. Ethnicity or Fitzpatrick skin type may be considered as risk factors. IEMP generally tends to regress spontaneously in months years without treatment. However, in our case, the disease runs an intractable and progressive course from year 7 to year 14. Similarly, a case of 21 year history of IEMP has been reported before, suggesting that IEMP may not be necessarily selfremitting. Topical steroids, hydroquinone, and tretinoin were not proved to be helpful in most reports. IEMP is a relatively rare disorder and should be considered as differential diagnosis for child or young adults with hyperpigmentation disorders. The management of IEMP may be difficult for extensive and nonremitting cases. Commercial support: None identified.
AB232
J AM ACAD DERMATOL
Transepidermal delivery of hydroquinone and clobetasol propionate using ablative fractional radiofrequency and ultrasound in the treatment of melasma Valeria Campos, MD, University of Jundiai, Jundiai, Brazil; Ana Flavia Salai, MD, Clinica Valeria Campos, Jundiai, Brazil; Natalia Roberta Castellen, MD, Clinica Valeria Campos, Jundiai, Brazil; Fernanda Barbosa, MD, Clinica Valeria, Brazil; Luiza Pitassi, PhD, University of Campinas, Jundiai, Brazil; Daniel Manor, MD, Clinica Valeria Campos, Jundiai, Brazil; Sully Freire Luz, Clinica Valeria Campos, Jundiai, Brazil Background: Melasma is a common disorder of hyperpigmentation that has a significant negative impact on the quality of life in affected individuals and is often difficult to treat. A range of treatments for melasma exist, with varying degrees of efficacy and success. Depigmenting agents have been the gold standard for the treatment of melasma for decades. But, some drugs that are absorbed do not penetrate deeply enough to reach the desired target in the tissue. Fractional ablation penetrates the skin by creating microchannels which reach beyond the stratum corneum, creating a direct path for drugs to reach the deeper skin tissue. Objective: This present study intends to evaluate the clinical efficacy and the safety of the combination of fractional ablative radiofrequency technology paired with an acoustic pressure wave ultrasound technology to topically push the 4% hydroquinone and 0.05% clobetasol propionate through the albeit perforated melasma treated skin. Methods: The study enrolled 20 patients of Fitzpatrick skin types I-IV with refractory facial melasma. Initially, patients were treated every other week, during 3 months (6 treatments) with fractional radiofrequency device (RF Pixel Microplasma) for skin perforation employing 50W and 1 pass, followed by acoustic pressure ultrasound. The treatment settings of the acoustic pressure ultrasound handpiece were 80% of the ultrasound energy output and 50 Hz for the ultrasound sonotrode vibration rate. Immediately 4% hydroquinone and 0.05% clobetasol propionate were applied on the perforated skin surface. Clinical and instrumental evaluations for improvement in pigmentation were conducted at baseline and at each subsequent follow-up visit at 2, 4, 8 and at 12 weeks. The effects of treatment were evaluated by three physicians not involved in the study and by standardized digital photographs (VISIA; Canfield Imaging Systems, USA) based on improvement of pigmentation and reduction in melasma size. Results: This study shows the improvement of melasma through the enhanced penetration of hydroquinone and clobetasol propionate using ablative fractional radiofrequency and ultrasound and acoustic pressure. The image analysis showed that hyperpigmentation was significantly reduced at 2, 4, 6 and 12 weeks after treatment. The therapy was well tolerated, safe and no adverse events were reported during the study. Conclusion: This study has demonstrated the improvement of melasma through the enhanced penetration of hydroquinone and clobetasol propionate by using a paired model for transepidermal drug delivery which could be a safe, tolerable, and effective alternative modality for the treatment of melasma. The RF Pixel Microplasma was lent to the group for this study.
MAY 2016