***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Melasma is one of the most common cosmetic disorders with skin darkening . Although several treatment modalities are available , none is satisfactorily used in management of this condition . Tranexamic acid ( TA ) , a plasmin inhibitor , is reported to improve melasma when injected locally or used as oral and topical forms . AIM The aim of this study was to compare therapeutic effects of liposomal tranexamic acid and conventional hydroquinone on melasma . METHODS Thirty women with bilateral melasma were enrolled in a split-face trial lasting 12 weeks . Patients blindly applied 5 % topical liposomal TA and 4 % hydroquinone cream , to the design ated sides of the face twice daily in addition to the assigned sunscreen in the morning . Skin pigmentation was measured using MASI ( Melasma Area and Severity Index ) at each visit separately for each side at the base line and every month until one month after treatment course . Data were obtained from patients file and were analyzed statistically using SPSS software , paired sample s t-test , and repeated measured ANOVA . RESULTS Twenty-three patients completed the study . The mean MASI scores significantly reduced in both treated sides ( P < P = 0.001 ) after 12 week . A greater decrease was observed with 5 % liposomal TA , although this difference was not statistically significant . Irritation occurred in three patients with hydroquinone , while no serious adverse events occurred with TA . CONCLUSION On the basis of these results , topical liposomal TA can be used as a new , effective , safe , and promising therapeutic agent in melasma ABSTRACT Background : Picosecond laser is a novel modality for pigmented skin disorders with extremely short pulse duration . Little is known about the effects of the picosecond laser in melasma . Objective : This study aim ed to investigate the efficacy of fractional picosecond 1,064 nm laser in melasma treatment . Study design : A prospect i ve , r and omized , assessor-blinded , intra-individual split face comparative study . Methods : Female subjects with melasma were enrolled and received fractional picosecond 1,064 nm laser plus 4 % hydroquinone cream on one r and omly assigned side of the face ; the results were compared to the use of hydroquinone cream only on the contralateral side . The modified melasma area severity index ( mMASI ) score , melanin index by Mexameter MX18 ® , participant satisfaction score by quartile rating scale , and the quality of life by the dermatology life quality index ( DLQI ) were evaluated over 12 weeks . Results : Thirty female subjects completed the protocol . The mean ( ± st and ard deviation , SD ) mMASI score at the 12-week visit was significantly reduced in the picosecond laser-treated areas compared to controls ( 3.52 ± 1.4 and 4.18 ± 2.03 respectively ; p = 0.035 ) . No differences were observed in the mean Mexameter melanin index , participant satisfaction score , and DLQI score . The observed adverse effects included transient mild erythema and mild skin desquamation . Conclusion : The addition of fractional picosecond 1,064 nm laser to 4 % hydroquinone was effective and significantly better than 4 % hydroquinone alone for the treatment of melasma Melasma is a macular hypermelanosis of the sun-exposed areas of the face and neck . The clinical efficacy of azelaic acid ( 20 % ) and hydroquinone creams ( 2 % ) in the treatment of this benign pigmentary disorder was compared in a r and omized , double-blind study with 155 patients of Indo-Malay-Hispanic origin . The creams were applied twice daily . A broad spectrum sunscreen was used concomitantly . Over a period of 24 weeks , 73 % of the azelaic acid patients , compared with 19 % of the hydroquinone patients , had good to excellent overall results , as measured by the reduction of melasma pigmentary intensity and lesion size . Transient mild to moderate irritant reactions were initially seen with both test drugs BACKGROUND Melasma is acquired symmetric hypermelanosis characterized by light-to-deep brown pigmentation over cheeks , forehead , upper lip , and nose . Treatment of this condition is difficult and associated with high recurrence rates . Chemical peels have become a popular modality in the treatment of melasma . OBJECTIVE To compare the therapeutic efficacy and tolerability of glycolic acid ( 35 % ) versus salicylic-m and elic ( SM ) acid ( 20 % salicylic/10 % m and elic acid ) versus phytic combination peels in Indian patients with melasma . MATERIAL S AND METHODS Ninety patients diagnosed with melasma were r and omly assigned into 3 groups of 30 patients each . Group A received glycolic acid ( GA-35 % ) peel , Group B received SM acid , and Group C received phytic combination peels . Each group was primed with 4 % hydroquinone and 0.05 % tretinoin cream for 4 weeks before treatment . Chemical peeling was done after every 14 days in all groups until 12 weeks . Clinical evaluation using melasma area and severity index ( MASI ) score and photography was recorded at every visit and follow-up was done until 20 weeks . RESULTS There was a decrease in MASI score in all 3 groups but it was statistically significantly lower in Group A than Group C ( p = .00 ) , and it was also statistically significantly lower in Group B than Group C ( p = .00 ) but there was no statistically significant difference between Groups A and B ( p = .876 ) . Objective response to treatment evaluated by reduction in MASI scoring after 12 weeks was 62.36 % reduction in GA group , 60.98 % reduction in SM group , and 44.71 % in phytic acid group . CONCLUSION It is concluded that GA ( 35 % ) and SM acid peels are both equally efficacious and a safe treatment modality for melasma in Indian skin , and are more effective than phytic acid peels . Salicylic-m and elic peels are better tolerated and more suitable for Indian skin BACKGROUND Melasma is difficult to clear . Many agents have been used , such as hydroquinone , and glycolic acid and glycolic acid peels , kojic acid , a tyrosinase inhibitor in the fungus Aspergilline oryzae . OBJECTIVE To see if the addition of 2 % kojic acid in a gel containing 10 % glycolic acid and 2 % hydroquinone will improve melasma further . METHODS Forty Chinese women with epidermal melasma were treated with 2 % kojic acid in a gel containing 10 % glycolic acid and 2 % hydroquinone on one half of the face . The other half was treated with the same application but without kojic acid . The side receiving the kojic acid was r and omized . Determination of efficacy was based on clinical evaluation , photographs and self- assessment question naires at 4 weekly intervals until the end of the study at 12 weeks . The non-parametric Wilcoxon 's rank sum test was used for statistical analysis . RESULTS All patients showed improvement in melasma on both sides of the face . The side receiving the kojic acid did better . More than half of the melasma cleared in 24/40 ( 60 % ) patients receiving kojic acid compared to 19/40 ( 47.5 % ) patients receiving the gel without kojic acid . In 2 patients , there was complete clearance of melasma , and this was on the side where kojic acid was used . Side effects include redness , stinging , and exfoliation . These were seen on both sides of the face , and they settled by the third week . CONCLUSION The addition of kojic acid to a gel containing 10 % glycolic acid and 2 % hydroquinone further improves melasma Abstract Background : Tranexamic acid ( TNA ) is a novel therapeutic agent for hyperpigmented skin disorders . The efficacy and safety of topical TNA in patients with melasma  has not been heretofore studied . The main objective of this study is to evaluate the efficacy and safety of topical TNA combined with intense pulsed light ( IPL ) treatment in Asians with melasma . Methods : A r and omized , split-face ( internally controlled ) study was conducted in 15 women who received four monthly sessions of IPL to both sides of the face .  Topical TNA or vehicle was applied to a r and omly assigned side during and after IPL treatment . Patients were followed up for 12 weeks after completing the IPL treatments . Baseline and follow-up melanin index ( MI ; measured by Mexameter ® , Courage and Khazaka , Cologne , Germany ) and modified melasma area and severity index ( mMASI ) scores were determined . Results : Thirteen subjects completed the study  without serious adverse events . MI and mMASI decreased significantly from baseline to 12 weeks after the last IPL treatment on the topical TNA side but not on the vehicle side . The efficacy of topical TNA in preventing rebound pigmentation after IPL treatment was also statistically significant . Conclusion : Topical TNA can be considered an effective and safe adjuvant to conventional treatment for melasma BACKGROUND Chemical peels and topical depigmenting agents have become a popular modality in the treatment of  melasma .  AIMS To compare the clinical efficacy of trichloroacetic acid peel 20%vs . Jessner 's solution peel vs. the topical mixture of hydroquinone 2 % and kojic acid . PATIENTS AND METHODS Forty five patients with melasma were r and omly assigned into three groups of fifteen patients each . Group A received Jessner 's solution peel , group B received trichloroacetic acid peel 20 % , and group C received topical hydroquinone 2 % and kojic acid . All patients were seen in follow-up period after 16 weeks ; clinical evaluation using Melasma Area and Severity Index ( MASI ) score and photography were recorded before and after treatment and after 16 weeks . RESULTS There was a decrease in MASI score in all three groups after treatment and after follow-up period but after treatment MASI score was statistically significantly lower in group A than group C ( P = 0.01 ) , and it was also statistically significantly lower in group B than group C ( P < 0.001 ) but there was no statistically significant difference between groups A and B. After the follow-up period , MASI score was statistically significantly lower in group A than group C ( P < 0.001 ) , statistically significantly lower in group B than group C ( P < 0.001 ) , and statistically significantly lower in group B than group A ( P = 0.035 ) . The statistical analysis was done through one-way anova followed by least significant difference ( LSD ) . CONCLUSION Trichloroacetic acid 20 % showed better results than Jessner 's solution as peeling agent and hydroquinone 2 % with kojic acid as a topical agent in the treatment of melasma ABSTRACT Background : A QS-NdYAG laser ( QSNYL ) and topical tranexamic acid ( TA ) have been widely used . However , no study has yet reported the efficacy of using both QSNYL and TA as a combined treatment for melasma . Objectives : To evaluate the efficacy and adverse effects of topical 3 % TA combined with 1064-nm QSNYL as a treatment for melasma . Methods : A r and omized , prospect i ve , split-face , controlled trial was conducted . A 1064-nm QSNYL was performed on the entire face at baseline and 4 weeks later . The participants were r and omly selected for application of topical 3 % TA on one side of the face and the vehicle treatment on the other side of the face for 8 weeks . Clinical responses were determined by mMASI scores , Mexameter ™ , and participants ’ evaluation . Results : Twenty-five participants completed the study . At the end of the study , the mMASI score significantly decreased in the combination treatment ( p < 0.05 ) , while no significant changes were observed in the laser-alone treatment . More than 80 % of the participants noticed a > 50 % improvement on the side with combination therapy at every follow-up visit . No serious adverse events were reported . Conclusion : Topical TA as an adjuvant demonstrated trends of better outcomes than QSNYL alone for the treatment of melasma BACKGROUND Melasma 's high prevalence and profound psychological impact on patients necessitate efficacious , economical , and safe therapeutic interventions . Adjunctive therapies such as tranexamic acid ( TA ) can enhance the therapeutic effect of st and ard treatments like hydroquinone 4 % cream ( HQ ) . OBJECTIVE To conduct an assessor- and analyst-blinded , parallel , superiority , r and omized controlled trial to compare the clinical efficacy and safety of oral TA plus HQ vs. HQ alone in melasma treatment . MATERIAL S AND METHODS A total of 100 eligible patients with symmetric facial melasma were assigned to the intervention ( 250 mg thrice daily oral TA plus HQ 4 % cream nightly ) or the control group ( HQ 4 % cream only ) . Following 3 months of treatment , MASI ( melasma area and severity index ) score reduction was calculated as the primary outcome measure . After a 3-month follow-up , relapse was also assessed . RESULTS A total of 88 patients completed the study . At the end of the 6-month period , the overall mean of the MASI score in the intervention group was 1.8 points lower than in the controls ( 95 % confidence interval , 0.36 - 3.24 , P = 0.015 ) but the relapse rate was not significantly different ( 30 % vs. 26 % in the treatment vs. control group , respectively ) . Side effect occurrence was also similar , but treatment satisfaction 
    Output:
    
Triple combination cream ( hydroquinone , tretinoin , and corticosteroid ) remains the most effective treatment for melasma , as well as hydroquinone alone .
Chemical peels and laser- and light-based devices have mixed results .
Oral tranexamic acid is a promising new treatment for moderate and severe recurrent melasma .
Adverse events from all treatments tend to be mild , and mainly consist of skin irritation , dryness , burning , erythema , and post-inflammatory hyperpigmentation .
Hydroquinone monotherapy and triple combination cream are the most effective and well-studied treatments for melasma , whereas chemical peels and laser- and light-based therapies are equal or inferior to topicals , but offer a higher risk of adverse effects .