Journal of Clinical and Aesthetic Dermatology

FEB 2018

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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29 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY February 2018 • Volume 11 • Number 2 R E V I E W TABLE 1. Summary of clinical studies evaluating the efficacy of natural ingredients as hypopigmenting agents NATURAL INGREDIENTS STUDY HYPOPIGMENTING MECHANISM COMPARISON PIGMENTATION DISORDER CONCLUSION LEVEL OF EVIDENCE* AZELAIC ACID (AZA) Randomized controlled, open- label trial (Farshi et al) 2 Mitochondrial oxidoreductase inhibition, DNA synthesis inhibition, Tyrosinase inhibition 20% AzA vs. 4% hydroquinone cream Melasma Melasma responded better to AzA during second treatment month IB Nonrandomized open-label trial (Kircik et al) 3 None PIH 15% AzA gel applied twice daily reduced PIH over 16 week period IIA Controlled trial (Dayal et al)** Glycolic acid peel with twice daily 20% AzA cream vs. 20% AzA cream Melasma At 12 weeks, AzA/glycolic acid combination has a statistically significant decrease in MASI score compared with AzA alone IIA Controlled trial (Mazurek)*** None PIH Dermocosmetics containing AzA showed improve- ment in pigmentation IIA ALOESIN Controlled Trial (Choi et al, 2002) 7 Tyrosinase inhibition, tyrosine hydroxylase, DOPA oxidase Aloesin vs. Arbutin vs. Aloesin/Arbutin UVR-induced hyperpigmentation Dose-dependent suppression in pigmentation with application of aloesin; synergism between arbutin and aloesin IIA MULBERRY RCT (Alvin et al) 11 Tyrosinase inhibition, melanogenesis inhibition, ROS Scavenger 75% mulberry extract Melasma Compared to placebo, 75% mulberry extract showed significant improvement in MASI score, average Mexamater measurements, and MelasQoL scores IB LICORICE EXTRACTS Split-face controlled clinical trial (Amer et al) 17 Tyrosinase inhibition (glabridin) None Melasma Sixteen out of 20 patients had an "excellent response" to 20% liquitin cream applied BID for four weeks Glabridin was more efficacious compared to HQ IIA Controlled Trial (Makino et al) 15 ROS cavenger (glabridin) None UVR-induced hyperpigmentation Skin brightener containing glabridin was shown to be clinically efficacious IIA RCT (Costa et al) 16 Disperses melanin (liquiritin) Cream with belides, emblica, and licorice vs. 2% HQ Melasma Although depigmentation was seen in both groups, no statistical difference in efficacy IB RCT (Zubair et al) 10 Disperses melanin (liquiritin) 4% liquiritin vs. 2% liquiritin and HQ Melasma 4% liquiritin significantly more effective than combination group IB *Level of evidence—IA: evidence from meta-analysis of randomized controlled trials; IB: evidence from at least one randomized controlled trial; IIA: evidence from at least one controlled study without randomization; IIB: evidence from at least one other type of clinical study; **Dayal SS. Combination of glycolic acid peel and topical 20% azelaic acid cream in melasma patients: efficacy and improvement in quality of life. J Cosmetic Dermatol. 2016 Aug 8; ***Mazurek K. Comparison of efficacy of products containing azelaic acid in melasma treatment. J Cosmetic Dermatol. 2016;15(3):269–282; PIH: post-inflammatory hyperpigmentation; MASI: Melasma Area Severity Index; UVR: Ultraviolet radiation; MelasQoL: The Melasma Quality of Life Scale; RCT: Randomized controlled trial; ROS: reactive oxygen species; HQ: hydroquinone

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