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IntroductionMelasma is a pigmentary and chronic disease which is diagnosed by detection of brown or gray patches on sun exposed areas of the face including forehead, nose, malar and mandibular (1). Commonly seen in women especially those with darker skin tone. Melasma can be histologically classified into three types according to the deposition of the hyperactive melanocytes at the epidermal, dermal or mixed type (both epidermal and dermal layer). *

The prevalence of melasma in the general population varies according to geographical locations and race. A prevalence of 8.8% in Hispanic women, 40% in South East Asian women and 20% in men have been reported (2,3). Melasma mostly affects women with Fitzpatrick phototypes III through VI.*Introduction

*Introduction Melasma Area and Severity Index MASI Score

*IntroductionPRP is a product of whole blood that has high concentration of platelets. It contains a number of different growth factors and other cytokines release through degranulation and stimulate healing of hard and soft tissues . Seven growth factors and three adhesion molecules had shown to exhibit higher concentration in PRP compared to whole blood. Thus, accelerating cell regeneration at the site of injection as well as during its topical application.

*IntroductionCurrently there is no randomized case controlled study or trial done using platelet rich plasma (PRP) therapy in treating pigmentation conditions or melasma. Therefore this case study try to demonstrate the efficacy and safety of intradermal PRP injection in adjunct to the conventional therapies of mixed melasma such as topical depigmenting agents, chemical or Q-switched Nd Yag laser in Asian patients.

*Cases PresentationSubject 1 profile: - 42 year old female with- Fitzpatrick skin type IV.- no known medical illness - did not take any oral contraceptive pill (OCP) - no hormone replacement therapy (HRT) - no significant aesthetic/surgical history

-She came with the complaint of having few patches of brown pigmentation on her both cheek for about 10 years but worsening for the past few years.

*Cases Presentation- Clinical examination showed that few patches of brown pigment macule on both malar and temporal area suggestive of mixed melasma. - 3 to 4 small bluish brown macules on her both cheeks which might be Hori nevus.

- was given depigmenting agents Pro-heal Serum (IS Clinic Products) which contains topical alpha arbutin twice daily and started on 1064nm Q-switched Nd Yag laser (Conbio RevLite) at 10Hz, spot size of 8mm, at the fluence of 2.0-2.3J/cm2 for 2 passes then spot size of 6mm at 3.0-3.6J/cm for 2 to 4 passes in monthly interval

*Cases Presentation- However her melasma pigmentation was not improving. Hence intradermal injection of PRP was added as adjunctive therapy to the above therapies started since Dec 2012 at monthly interval.

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*Subject 2 profile: - 51 year old female - no known medical illness - Fitzpatrick skin type V. - no OCP, HRT, anti-convulsant or thyroid medications.- no significant aesthetic/surgical history

- She concerned about the large patches of brown pigmentation on her both cheeks for about 15 years. Cases Presentation

*- Clinical assessment showed irregular brown pigment macules over both malar areas with telangiectasia suggestive of mixed melasma.- treated with laser at other centre with no improvement. - given topical Pro-heal Serum (IS Clinic Products) contains alpha arbutin twice daily and started on 1064nm Q-switched Nd Yag laser (Conbio RevLite) at 10Hz, spot size of 8mm at the fluence of 1.8-2.1J/cm2 for 2 passes then spot size of 6mm at 2.8-3.1J/cm for 2 to 4 passes in monthly interval from June 2013 to September 2013. Cases Presentation

*- In view of her concern of dry skin with fine lines and telangiectasia, intradermal injection of PRP was offered for the pigmentation area accompany the above Q-switched laser session at monthly interval since June 2013.Cases Presentation

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*The side effects and complications observed in this case study were minimal and tolerable to the subjects with the application of local anesthetic cream thoroughly, meticulous injection techniques and application of the cooling mask or cold compression. Both subjects experienced mild erythema, edema and small needle prick mark bruises for the first few days after the PRP therapy. The erythema and edema were resolved within one to two days. The bruises were lasted slightly longer for about 4 to 5 days if the injections of the PRP had injured some of the small blood vessels. Results

*In the 3 months follow up, the recurrence or rebound of melasma for subjects 2 was as high as mean MASI score 53% which was higher than other study. This might be due to the loss of inhibitory effects of melanogenesis by PRP therapy in which the PRP effects is transient and the growth factors released once in a time. The recurrence melasma also would be more common for higher Fitzpatrick skin type patients which had been reported in other studies.

Results

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*Melasma is common among the Asian female population in which they are resistance to the conventional therapies. It is advisable for the melasma patients to have maintenance therapy to prevent recurrence of the melasma especially in the higher Fitzpatrick skin type patients. Conclusion

* In this case study, minimal side effects were observed in the intradermal PRP injection including pain, erythema, oedema and bruises. PRP therapy which serves as a source of different growth factors might help to reduce the pigmentation of melasma in some cases via the alternative biochemical pathway synergistic to the conventional therapies. Conclusion

*Nevertheless, this case study can be served as a pilot study for using PRP injection to treat melasma in adjunct to other conventional melasma therapies. It will be more benefit to the melasma patients if there are multi-centre studies done in larger sample size with control group to evaluate the effect of PRP injection in melasma patients with the different skin types.Conclusion

Thank You*

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