A STUDY OF EFFICACY RESULT BETWEEN TOPICAL HERBAL RHUBARB LIQUID AND LIQUID BASE FOR THE TREATMENT OF MELASMA IN THAI PEOPLE

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1 A STUDY OF EFFICACY RESULT BETWEEN TOPICAL HERBAL RHUBARB LIQUID AND LIQUID BASE FOR THE TREATMENT OF MELASMA IN THAI PEOPLE Zhang Hui Dermatology science, School of Anti Aging and Regenerative Medicine, Mae Fah Luang University, Bangkok, Thailand dr.huizhang@gmail.com Abstract Melasma is a common pigmentary disorder often seen in patients with skin phototypesⅢtoⅣ. Worldwide prevalence is variable. Clinically, it is typically described as a symmetric, welldemarcated, irregularly shaped, macular hyperpigmentation most often affecting the face with characteristic distribution in various well-recognized patterns (centrofacial, malar, mandibular, mixed). Histologically, the abnormal pigmentation may be found in the epidermis, the dermis, or both. Treatment options include topical bleaching regimens, chemical peels, and light and laser modalities. Rhubarb liquid extract also called Rheum emodi, has an antioxidant effect, antityrosinase and skin lightening effect. However, it will be a new topical herb for melasma treatment. A study of efficacy result of topical herbal Rhubarb liquid for the treatment of melasma in Thai people Thirty one patients (men and women, aged years old) with melasma were enrolled to this randomized, split face comparative study. The patients were enrolled and randomly assigned Rhubarb extract liquid on one side and placebo on the other side twice daily for 8 weeks with follow up every 4 weeks. Mexameter measurement were perfomed along with photography by VISIA Analysis at baseline, 4th week, 8th week and 12th week. Adverse events and satisfaction score were observed and recorded throughout the study. All the patients completed the study. The mean age of the patients was 35.42±9.381 years, with the majority of age of years old (12/31). While the majority of patients has Fitzpatrick skin type Ⅲ (23/31), and the other were type Ⅳ (8/31). There is 74.19% patients does not have family history of melasma. Most patients showed melasma improvement with both treatments. The follow up result after treatment on 12 th week showed that the mean melanin index (Rhubarb/placebo) was rebounded to (201/221.17), but result is still significantly lower than mean melanin index before treatment at baseline week. There is no serious side effects of these both liquid. the side effects were found in two patients with melasma(2/6.45%). 3 patients (9.68%) with melasma which use placebo liquid, cause by without use sun-scream. No significant improved of melasma between Rhubarb extract compared with placebo Keywords: Melasma, Rhubarb,topical herbal. 49

2 Introduction: Melasma is the frequent complaints in dermatological consultation. Melasma is an acquired hypermelanosis characterized by the development of symmetrical, irregular light-to-dark brown macules and patches on sun-exposed areas of the skin, especially on the skin of the face (Kwon SH, Park KC (2014). It is common among Asian and Hispanic women who are in their third or fourth decades of life. Three patterns of melasma are recognized clinically that are based on the distribution of the hyperpigmentation on the face, namely, the centrofacial, malar, and mandibular patterns. However, melasma often presents as a mixture of these patterns. Factors involved in the pathogenesis of melasma include a genetic predisposition, chronic exposure to ultraviolet (UV) radiation, and female sex hormones. However, the pathogenesis of melasma has not yet been fully elucidated. Risk factors have been associated with among women with Dark-haired persons (Fitzpatrick skin types III VI) are more susceptible to melasma and also topical cosmetics and fragrances as well as phototoxic drugs can also trigger or aggravate melasma. Diagnostic uncertainty when a patient presents with melasma-like findings can lead to suboptimal treatment and inaccurate prognostic expectations, and its management is challenging because it is a chronic condition with common recurrences and is often difficult to treat provoking significant emotional and psychological effects in affected patients (J Clin Aesthet Dermatol. 2016). The 1 st line therapy usually consists of topical treatment that affect the melanin synthesis pathway, broad spectrum photo protection, and camouflage. Although tretinoin is an effective treatment for melasma, its often produces irritation and requires a mean treatment duration of 6 months to demonstrate significant improvement; so it is not considered a first-line therapy for melasma. In this research, the study had compared melasma treatment by appling Rhubarb extract liquid and placebo by comparing its efficacy from photographs of VISIA Analysis, mean melanin index measured by Mexameter MX 18, comparing side effects and participant satisfaction. Objectives: A study of efficacy result of topical herbal Rhubarb liquid for the treatment of melasma in Thai people Materials and methods: Thirty one patients (men and women, aged years old) with melasma were enrolled to this randomized, split face comparative study. The patients were enrolled and randomly assigned Rhubarb extract liquid on one side and placebo on the other side twice daily for 8 weeks with follow up every 4 weeks. Mexameter measurement were perfomed along with photography by VISIA Analysis at baseline, 4 th week, 8 th week and 12 th week. Adverse events and satisfaction score were observed and recorded throughout the study. Statistic for data analysis: The participant research profile data, evaluation of patient satisfaction and complication were analyzed using descriptive statistical analysis. Comparison of mean melanin index of one side that applied Rhubarb extract liquid or one side that applied placebo before treatment with 50

3 after treatment at 4 th, 8 th and 12 th week used paired t-test statistic. T-test was used to analyze comparison of mean melanin index of one side that applied Rhubarb extract liquid and one side with placebo.the data was analysed using SPSS.p-values<0.05 were considered statistically significant. Results: All the patients completed the study. The mean age of the patients was 35.42±9.381 years, with the majority of age of years old (12/31). While the majority of patients has Fitzpatrick skin type Ⅲ (23/31), and the other were type Ⅳ (8/31). There is 74.19% patients does not have family history of melasma. Most patients showed melasma improvement with both treatments. The follow up result after treatment on 12 th week showed that the mean melanin index (Rhubarb/placebo) was rebounded to (201/221.17), but result is still significantly lower than mean melanin index before treatment at baseline week. There is no serious side effects of these both liquid. the side effects were found in two patients with melasma(2/6.45%). 3 patients (9.68%) with melasma which use placebo liquid, cause by without use sun-scream. Mean Melanin Index Comparison baseline week 4 week 8 week 12 rhubarb placebo Satisfaction score: In addition, the participants were significantly satisfied with the result of both liquid. Table 4.6 Statistical analysis of mean melanin index between Rhubarb extract liquid and Placebo. rhubarb placebo Mean SD Mean SD P-value baseline week week week Note: P-value compared between 2 groups with t-test 51

4 The follow up result after treatment on 12 th week showed that the mean melanin index (Rhubarb/placebo) was rebounded to (201/221.17), but result is still significantly lower than mean melanin index before treatment at baseline week. Discussion : Melasma is the frequent complaints in dermatological consultation. Melasma is an acquired hypermelanosis characterized by the development of symmetrical, irregular light-to-dark brown macules and patches on sun-exposed areas of the skin, especially on the skin of the face (Kwon SH, Park KC (2014). It is common among Asian and Hispanic women who are in their third or fourth decades of life. The aim of therapy one in treatment of melasma is to reduce the amount of melanin production with or without reduction in number of melanocytes, most of the therapies were difficult and associated with many complications and high relapse rate. There are many varieties of topical therapy : hydroquinone, retinoids,azelaic acid, kojic acid, ascorbic acid, arbutin/deoxyarbutin. In this research, the study had compared melasma treatment by appling Rhubarb extract liquid and placebo by comparing its efficacy from photographs of VISIA Analysis, mean melanin index measured by Mexameter MX 18, comparing side effects and participant satisfaction. In contrast to decrease of mean melanin index, the satisfaction score were rated throughout the study. The satisfaction score were rated from 1-5 which is 1=little satisfaction, 2=moderate satisfaction, 3=satisfied, 4=most satisfied and 5=not satisfied. After treatment with Rhubarb extract liquid, 23 patients (79.31%) rated their satisfaction as most satisfied. 5 patients (17.24%) rated as satisfied. One patient (3.45%) rated as the moderately satisfied. After treatment with placebo liquid, 7 patients (24.14%) rated their satisfaction as most satisfied. 16 patients (55.17%) rated as satisfied. 6 patient (20.69%) rated as the moderately satisfied. The p-value compared between Rhubarb and placebo liquid on 12 th week is Additionally, after being treated using Rhubarb extract liquid, the side effects were found in two patients with melasma(2/6.45%). 3 patients (9.68%) with melasma which use placebo liquid, cause by without use sun-scream. We observed that the evolution time of melasma did not affect the response to treatment. Conclusion: Through a self-controlled study of the left and right face, we can determine whether this association of active ingredients can be applied to improve and prevent facial hyperpigmentation. The treatments used in this study proved to be the safe treatment options for patients with melasma, including darker skin types. Rhubarb extract liquid and placebo liquid can accoplish good outcomes in 4 th week and 12 th week. This is possible due to fact that all volunteers suggested to used sunscreen until this study finished. This treatment may be a useful alternative when allergen with another topical treatment or have more side effect medicine. It can reduce melanin production in human with low cost, offer another benefits as a strong antioxidant, and well tolerated side effect. Suggestion: In future studies, a larger cohort of patients should be recruited to be better compare treatment outcomes in melasma. Moreover, due to many precipitating factors of melasma, we suggest further investigation in a longer period study, and long term follow up. Clinical 52

5 improvement was both objective and subjective verified. Treating melasma with Rhubarb extract liquid is reatively simple, noninvasive and less side effect. It does not affect patient s daily life activities, hence, proved to be suitable option for periodic treatment. References: 1. Kwon SH, Park KC (2014) Melasma and common pigmentarydermatoses inasian individuals and an overview of their treatment. J ClinInvestigatDermatol 2:8. 2. OCHI HARUMI, MBBS; CHEE LEOK GOH, MD, MBBS, M.MED (INT. MED), MRCP (UK), FRCP (EDIN), FAMS. National Skin Centre, Singapore. The Effect of Melasma on the Quality of Life in a Sample of Women Living in Singapore. J ClinAesthetDermatol. 2016;9(1):