الفهرس 
Acknowledgement
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Abstract
The current study was carried out at the Dermatology, Venereology and Andrology outpatient clinic of Assiut University Hospitals, Egypt, in the period between July 2017 and May 2019.The study designed to evaluate the efficacy and safety of combined microneedling and TCA peeling in the treatment of melasma. Fourty melasma patients were recruited in this study. Patients were randomly classified in to two groups; group (A) included 20 patients were treated with TCA 25 % peeling sessions every 2 weeks (8 bimonthly sessions) and combined with microneedling sessions every 4 weeks (4 monthly session) and group (B) included 20 patients were treated with TCA 25 % alone every 2 weeks (8 sessions).The evaluation of improvement was assessed by objective and subjective methods which were done by MASI score, mMASI score and MSI for each patient at the baseline, one and three months after the last session, which were done by photographic assessement by two blinded dermatologists, physician assessment using six grade scale, patient satisfaction using four grade scale and adverse effects were also reported. The age of the patients ranged from 20 to 48 years with a mean ± SD of 32.50 ± 6.19 in group A and 36.05 ± 5.72 in group B. Most of the patients had skin phototype IV (70% in group A and 80% in group B). Sun exposure was the most prevalent triggering factor in about 85% of patients in group A and 95% in group B. All mean scores in group A ( MASI, m-MASI and MSI) were observed to show a significant decrease at 1 month and 3 months after the last session (p value <0.05). However, no significant difference was revealed on comparing the mean MASI, m-MASI and MSI scores after 1 month and after 3 months of treatment. Regarding type of melasma after examination by wood’s light, at the baseline, 1ms and 3 ms after treatment in group A ; the mean MASI, m-MASI and MSI scores were revealed significantly decrease in epidermal type. After 1ms and 3 ms of treatment, both types (epidermal and mixed ) showed decline in all scores, this decline reached a significant level in the epidermal type only On evaluating the clinical response using six grade scale, 30% of patients showed excellent response, 45% showed good response while 15% of patients showed moderate response after 1month and 3 months of treatment with no difference between both follow up duration. Regarding patient satisfaction, after 1month of treatment, about 30% of patients were very satisfied, 45% satisfied while 15% slightly satisfied. After 3 months of treatment, the patient satisfaction did not change Regarding adverse effects following treatment, about 35% showed burning sensation, 25% of patients showed burning sensation combined with transient erythema,15% showed transient erythema only and one case showed folliculitis. All adverse effects were treated completely in between the sessions without any residual or the need to stop the sessions.