الفهرس 
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Abstract
Melasma is a common pigmentary disorder that manifests as symmetric hyperpigmented macules and patches on the face. The prevalence of melasma varies between 1.5% and 33.3% depending on the population. It typically affects women of reproductive age with Fitzpatrick skin type IV-VI, though the condition can occur in men also. Genetic predisposition, ultraviolet (UV) radiation exposure, hormonal factors such as female sex hormones and thyroid disease, pregnancy and drugs like phenytoin are the known risk factors.
Melasma has a profound effect on patients’ quality of life.The most likely affected by melasma in quality of life are; social life, recreation and emotional well-being.
Melasma treatment may be frustrating as many modalities can turn out to be ineffective. Dermal and mixed variants are quite resistant to therapy. Most patients seek medical help much after the onset of the condition, making treatment even more difficult. Sunscreens and topical depigmenting agents remain mainstay of therapy. Chemical peels, light sources and laser are beneficial as adjuncts.
Microneedling is a very simple, safe, effective, and minimally invasive therapeutic technique. It was initially introduced for skin rejuvenation, however, now it is being used for a very wide range of indications including acne scar, post traumatic/burn scar, alopecia, skin rejuvenation, transdermal drug delivery, hyperhidrosis, stretch marks. Microneedling enhances the delivery of various drugs across the skin barrier as it bypasses the stratum corneum and deposits the drug directly up to the vascularized dermis. It has also been shown to cause significant widening of the follicular infundibulum by 47%, which may partly
explain the increased penetration of the medication across the skin barrier.
Tranexamic acid (TA), a plasmin-inhibitor hydrophilic drug, classically used as antifibrinolytic agent, has been studied as an alternative for treatment of melasma. Oral, topical and microinjection of tranexamic acid, in addition to dermaroller microneedling delivered TA were studied. However, route of administration, frequency of usage, long-term benefits and effect of combination of TA with antimelasma agents, as well as the mechanisms by which TA can participate in melasma treatment, need to be fully elucidated.
The aim of this work was to elucidate the efficacy and safety of tranexamic acid in treatment of melasma through its dermapen delivered microneedling sessions plus its topical use in between sessions. In addition, we also aimed to compare its lone use versus its use (miconeedling sessions) in combination with Kligman’s formula in between sessions.
This study was carried out on 40 patients having melasma. The patients were selected from Dermatology Outpatient Clinic, Faculty of Medicine Menoufia University Hospital during the period between September 2015 and May 2016. A written consent form, approved by The Committee of Human Rights in Research of Menoufia University was signed by every participant before study initiation.
All participants instructed not to use any other product for treatment of their melasma at the time of the study. They were subjected to complete history taking, clinical examination including MASI score assessment, digital photographic registration and punch biopsies from lesional skin.
All participants were treated by dermapen delivered TA microneedling sessions (once ⁄ week for 12 weeks), and according to the in between sessions used medications, they were divided into 2 groups; group I: included 20 patients using topical tranexamic acid emulgel twice daily, group II: included 20 patients using topical kligman’s formula cream at night.
At the end of the study; the therapeutic effects and side effects were studied by evaluating MASI score, MASI score improvement percent, photographic evaluation, patient satisfaction and histopathological evalution.
Our study showed a significant improvement in both studied melasma patients groups one week after the last session, MASI score mean values showed significant decrease in both groups (p=0.00), with a significant improvement in degree of melasma severity in group I (p=0.018). Compared to group II, group I showed more significant decrease of MASI score mean value (p=0.04).The percent of MASI score improvement in group I was non significantly higher than that in group II (p=0.424).
Most of patients in group I (9, 45%) patients showed excellent degree of satisfaction, while 6 (30%) patients showed good, 4 (20%) patients showed fair and one (5%) patient showed poor degree of satisfaction, while in group II 7 (35%) patients showed excellent degree of satisfaction, 7 (35%) cases had good, 2 (10%) cases had fair and 4 (20%) patients showed poor degree of satisfaction. There was no significant difference between the two studied melasma patient groups (I and II) regarding degree of patient satisfaction after treatment (p= 0.425).
Haematoxylin and eosin stained sections in melasma patients before treatment showed epidermal atrophy with loss of reti ridges,
pigmented basal cell layer, pendulous melanocytes, and thickened basement membrane. The observed dermal changes were melanin incontinence chronic inflammatory infiltrates, congested blood vessels, increased mast cells and solar elastosis (VG stain).
After treatment, there was a significant improvement in all evaluated histopathological epidermal and dermal changes in both studied groups except for congested blood vessels and number of mast cells in group II.
There was a significant association between patient satisfaction and percent of MASI score improvement in melasma patients in group I as well as in group II (P= 0.001, P=0.028) respectively. Also percent of MASI score improvement was significantly associated with mast cells count improvement in group I (p= 0.030) and group II (p= 0.020).
There were no significant relations between percent of MASI score improvement and any of studied personal and clinical data in both melasma groups (p> 0.05 for all).
Only erythema, local bruising and post inflammatory hyperpigmentation were the observed side effects in this study.