Topical tranexamic acid is a promising treatment for melasma. Tranexamic acid (TA) has been reported to have whitening effects especially for ultraviolet-induced hyperpigmentation including melasma. The aim of a 12-week double-blind split-face trial was to evaluate a topical solution of TA and compare it with combined solution of hydroquinone and dexamethasone as the gold standard treatment of melasma. Fifty patients applied topical solution of 3% TA on one side of the face, and topical solution of 3% hydroquinone + 0.01% dexamethasone on the other side twice daily. The Melasma Area and Severity Index (MASI) and the side effects were evaluated at baseline and every 4 weeks, and photographs taken before and after were compared by a dermatologist. A significant decreasing trend was observed in the MASI score of both groups with no significant difference between them during the study. No differences were seen in patients' and investigators' satisfaction of melasma improvement between two groups. However, the side effects of hydroquinone + dexamethasone were significantly prominent compared with TA. This study's results suggest that topical tranexamic acid may be preferred over hydroquinone + dexamethasone for the treatment of melasma.

   Topical tranexamic acid has also been studied as an adjuvant treatment in melasma. The main objective of the following study was to evaluate the benefits of topical TA combined with intense pulsed light (IPL) treatment in Asians with melasma. A randomized, split-face (internally controlled) study was conducted in 15 women who received four monthly sessions of IPL to both sides of the face. Topical TA or vehicle was applied to a randomly assigned side during and after IPL treatment. Patients were followed up for 12 weeks after completing the IPL treatments. Baseline and follow-up melanin index (MI) and modified melasma area and severity index (mMASI) scores were determined. Thirteen subjects completed the study without serious adverse events. MI and mMASI decreased significantly from baseline to 12 weeks after the last IPL treatment on the topical TA side but not on the vehicle side. The prevention of rebound pigmentation by topical application of TA after IPL treatment was also statistically significant. Topical TA can be considered as an adjuvant to conventional treatment for melasma.
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      Melasma is a common acquired pigmentary disorder that occurs usually in women (more than 90% of cases) of all racial and ethnic groups. Melasma is an acquired increased pigmentation of the skin characterized by symmetrical and confluent grey-brown patches usually on the areas of the face exposed to the sun. Silymarin (also known as milk thistle) strongly prevents photocarcinogenesis, and significantly prevented melanin production. A study assessed the  benefits of topical Silymarin (SM) cream in a double-blind placebo controlled study for treatment of 96 adult melasma patients seen at an outpatient clinic.

   Patients were randomized in a double-blind manner to receive one of the following treatments: Group I (G I) SM (7 mg/ml) cream, Group II (G II) SM (14 mg/ml) cream, or Group III (G III) placebo, applied topically to the affected areas, twice daily for 4 weeks. Patients were also advised to avoid sun exposure and to use topical sunscreen with sun protection factor (SPF) of 15+ during the entire period of treatment and thereafter. The patients were seen regularly every week for one month for assessment; the response to treatment was evaluated by the response; lesion size, melasma area and severity index score, physician global assessment, and subjective assessment.

  Clinically, patients treated with topical silymarin showed significant excellent pigment improvement & lesion size reduction from the 1st week. Silymarin significantly prevented melanin production in a dose-dependent manner. Silymarin showed tremendous improvement of melasma in a dose-dependent manner, and was effective in prevention of skin damage caused by U.V. sunlight. Patients' satisfaction was recorded as 100%. During the period of treatment, no local or systemic adverse effects were observed.

     A study evaluated a topical treatment of silymarin and methylsulfonylmethane (dimethyl sulfone, MSM) to improve erythematous-telangiectactic rosacea. Forty-six patients affected by stage I-III rosacea entered this double-blind, placebo-controlled study. Subjects were treated for 1 month. Clinical and instrumental evaluations were done at baseline, after 10 and 20 days, and at the end of the study. Itching, stinging, erythema, and papules were investigated clinically as well as hydration and erythema instrumentally with capacitance and color measurements. A statistically significant improvement was observed in many clinical and instrumental parameters investigated. In particular, improvement of skin redness, papules, itching, hydration, and skin color occurred.

   The combination of silymarin and S-MSM can be useful in managing symptoms and the condition of rosacea skin, especially in the rosacea subtype 1 erythemato-telangiectatic phase. The action can be considered multicentric and multiphasic because of the direct modulating action on cytokines and angiokines normally involved and up-regulated in this skin condition.

     More than 80% of patients with breast cancer who undergo postsurgical radiation therapy (RT) will develop radiodermatitis and approximately 10% of these patients show grade 3 lesions. Side effects may reduce the patient's compliance with RT protocols. Therefore, there is a need for prophylactic treatments. A total of 101 patients were evaluated after breast-conserving surgery followed by RT with 50.4 Gy plus boost 9-16 Gy. Of these, 51 patients were treated with a silymarin-based cream. Fifty patients received a panthenol-containing cream interventionally if local skin lesions occurred (the standard of care at the hospital; SOC). The median time to skin reaction to radiotherapy was prolonged significantly with silymarin-based cream (45 vs. 29 days for SOC). Only 9.8% of patients using silymarin-based cream showed grade 2 toxicity in week 5 of RT in comparison to 52% with SOC. At the end of RT, 23.5% of patients in the silymarin-based study group developed no skin reactions vs. 2% with SOC, while grade 3 toxicity occurred only in 2% in the silymarin-based group compared to 28% with SOC. The study concluded that a silymarin-based cream may be a promising treatment for the prevention of acute skin lesions caused by RT in breast cancer patients. Larger studies need to be done to confirm the results of this nonrandomized, observational trial.