الفهرس 
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Abstract
Melasma is an acquired pigmentary disorder which is manifested as hyperpigmented macules and patches symmetrically distributed on the face, neck, and rarely the upper limbs. It is more common in women with darker complexions of childbearing age. According to their clinical presentation, facial melasma lesions can be classified into two types: centrofacial and peripheral. The exact etiopathogenesis is not clear, but factors including sun exposure, pregnancy, hormonal factors and genetic predisposition have been implicated in the pathogenesis. Melasma has traditionally been treated with a combination of photoprotection, avoidance of trigger factors, topical depigmenting agents, chemical peels and laser and light therapy with varying degrees of success. Despite these numerous therapies, a high recurrence rate and variable results remain challenges in the treatment of melasma, and combination treatment using multiple modalities is often necessary. The present study was conducted on 28 patients selected from the Dermatology Outpatient Clinic, NILES. All patients (88%) were females and (4%) were male. Their ages ranged 35 to 65 years with a mean of 44.67 ± 6.3. Improvement in melasma, as well as a decreased incidence of PIH was achieved after development of fractional photothermolysis. This is due to the enhanced healing times and decreased inflammation as a result of the formation of microscopic columns of tissue destruction.These microscopic columns of damaged tissue are surrounded by areas of normal tissue, allowing for shorter migratory paths for the healing keratinocytes, thus leading to decreased incidences of PIH even in individuals with darker skin phototypes. Also the microepidermal necrotic debris (MEND) extruded after fractional thermolysis contains melanin .The MENDs are proposed to act as „melanin shuttles‟ that lead to depigmentation of the epidermal and dermal layers by means of packaging excess melanin, that will then be eliminated through the stratum corneum. Tranexamic acid, a plasmin inhibitor, has been suggested as an effective treatment for melasma with promising results. Several forms of TA, including oral, topical and localized microinjection forms, have been shown to improve melasma. Topical TA shows rapid and more sustained results with very minimal adverse effects as far as epidermal melasma is concerned, and the drug has been proven to have almost similar cumulative effects of hydroquinone and dexamethasone. In the present work, the clinical improvement was demonstrated after 4 consecutive sessions 4 weeks apart. The half face was subjected to Erbium-YAG laser. Otherside was assigned to intradermal injection of Tranexamic acid solution. Sessions were received every 4weeks for 4 consecutive sessions. Assessment was done using the MASI score, dermoscopy, photography assement before sessions and three months after the last session. After treatment, significant reduction in the MASI score was noted in both right and left (laser and intradermal) sides (p value 0.004, 0.000003 respectively). On comparing the degree of improvement between the different treatment modalities, the degree of improvement regarding the MASI score was better with intradermal injection (2.81(±2.09) than Erbium YAG laser (3.83 (±2.63). Depending on photographic assement, the right sides which were treated with TA showed improvement with excellent response in eight patients (29.6%). Seven patients showed fair response (25.9%). On the other hand, the laser treated sides showed an excellent response in 3 patients only (11.1%) whereas nine patients showed fair response 9(33.3%). The evaluation which was done by the two independent dermatologist showed the same degree of agreement these evaluation were compared as following: group A weighted kappa: 0.711(Good agreement), group B weighted kappa: 0.67 (Good agreement) . In this study, the patient satisfaction scale was the same for both sides. Tewlve patients (44.4%) reported their improvement as excellent; seven patients (25.9%) as good; with no patients reviews bad at intradermal injection in comparison to laser 3 (11.1%) patients feel bad and seven patients (25.9%) feel excellent . Our patients showed minimal complications. Two patients suffered post-inflammatory hyperpigmentation. All patients suffered mild burning pain after the procedure which lasted for few hours. In conclusion, Tranexamic acid intrademally might add to be more effective than Er-bium YAG laser and safe treatment for Melasma.