الفهرس 
Introduction
The epidermisOnly 14 pages are availabe for public view
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Abstract
This study was conducted at the Department of Dermatology, Venerology and Andrology, Department of Pathology and the Department of Clinical Pathology, Assiut University Hospital, Egypt, in the period from November 2015 to December 2016, to evaluate the efficacy of PRP in the treatment of melasma using two different delivery methods.
Twenty three melasma patients were recruited from the outpatient clinic of the Depertment of Dermatology, Venerology and Andrology, Assiut university hospital.
Patients were subjected to treatment with PRP using two different injection techniques for each side of the face, where microneedling using dermapen followed by PRP topical application on the right side of the face, while for the left side PRP was delivered through microinjections using mesoneedles. This was done monthly for three sessions with the final evaluation was done one month after the last session. The response to treatment was assessed with photographs taken for the patient before every session and one month after the last one, along with MASI and hemi-MASI scores at the baseline and one month after the last session. The percent of improvement in the MASI and hemi-MASI scores was graded on a four level scale, with improvement percentage ranging from 0 to <25 was regarded as slight improvement, from 25% to <50% for moderate improvement, from 50% to <75% for significant improvement and >75% for excellent improvement.
Two millimeter (mm) punch biopsies were obtained from the lesional skin of 20 out of 23 patients (before and after treatment with PRP) and from the perilesional skin of only ten of them, to be evaluated for immunohistochemical TGF-β protein expression and compared to the expression in the healthy control skin obtained from the face of nine volunteers.
The participating patients included 19 female and 4 males with age ranged from 21 to 50 years old with the mean age was 32.35 ± 5.87. Fitzpatrick skin phototypes of the patients were III and IV, and the duration of illness ranged from one to twelve years with a mean duration of 4.59 ± 3.04.
All patients gave history of sun/heat exposure. However, 69.6% of them reported sun/heat exposure as the main triggering factor, whereas pregnancy and hormonal contraception were reported to be the main trigger in 17.4% and 13% of the patients, respectively. Epidermal melasma was present in 18 (78.3%) patients, while mixed melasma was found in only 5 (21.7%) patients.
There was significant decrease in the MASI score from the baseline after treatment with PRP. Evaluation of the degree of improvement in the MASI score after treatment revealed that excellent improvement was in 3 (13%) patients, significant improvement was in 5 (21.7%) patients, moderate improvement was observed in 10 (43.5%) patients, and slight improvement was observed in 5 patients (21.7%).
Both techniques used for PRP delivery into the dermis was associated with significant decrease in the hemi-MASI score after treatment from the baseline p value < 0.05, with no significant difference between both sides. Also, this decrease was significantly greater in patients with epidermal melasma than those with the mixed type p value < 0.05.
As regards the degree of patients’ satisfaction, 39.1% of the patients were very satisfied, 39.1% were satisfied, 13.1% reported slight satisfaction and only 2 patients were unsatisfied with their improvement (8.7%).
Transdermal PRP delivery through microneedling using dermapen was better than intradermal PRP microinjections using mesoneedles in terms of tolerability by the patients (less painful) and safety to the physician with no significant statistical difference in the percent of clinical improvement. However, the downtime after microneedling with dermapen was reported by the patients to be a little bit longer than that for microinjections with mesoneedles.
Histological features of melasma skin (before and after PRP treatment) using routine (H&E) and special (PAS and Giemsa stain) were studied. In the lesional/melasma skin before treatment changes included basal cell layer hyperpigmentation, dermal melanin incontinence and melanophages, and capillary ectasia. PAS staining revealed basement membrane irregularities and disruptions of the lesional/melasma skin before treatment. Also, increased mast cell numbers was salient with Giemsa staining of the lesional skin before treatment. On the other hand, decreased pigmentation of the basal cell layer, absence of melanin incontinence and melanophages in the dermis, with healing of the basement membrane disruption and decreased mast cells numbers were noted on evaluation of the lesional after PRP treatment.
TGF-β protein was variably expressed within the epidermis as well as the dermal adnexal structures, vascular endothelium, nerves and the arrector pili muscle fibers of the healthy skin (control), the skin adjacent to melasma lesions, and the lesional melasma skin before and after treatment with PRP. In the healthy skin the mean value of TGF-β expression was 2.26 ± 0.37. The expression in the perilesional skin was signficantly lower (1.68 ± 0.51) than that in the healthy skin (p value<0.05). In the lesional melasma skin TGF-β protein was significantly downregulated as compared to both healthy and perilesional skins, the mean expression was 1.26 ± 0.41. However, following treatment with PRP the expression of TGF-β protein was significantly upregulated in the lesional melasma skin. The mean value of expression was 2.15 ± 0.44. It approached the mean expression in the healthy skin with no significant difference (p value>0.05).