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A Comparative Study of the Safety and Efficacy of 75% Mulberry (Morus alba)
Extract Oil Versus Placebo as a Topical Treatment for Melasma: A Randomized,
Single-Blind, Placebo-Contr...

Article in Journal of Drugs in Dermatology · September 2011

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 September 2011 443 Volume 10 • Issue 9
Copyright © 2011 ORIGINAL ARTICLES Journal of Drugs in Dermatology

A Comparative Study of the Safety and Efficacy

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of 75% Mulberry (Morus alba) Extract Oil Versus
Placebo as a Topical Treatment for Melasma: A
Randomized, Single-Blind, Placebo-Controlled Trial
Glen Alvin MD, Nino Catambay MD, Ailynne Vergara MD, Maria Jasmin Jamora MD
Skin & Cancer Foundation (SCF), Manila, Philippines

ABSTRACT

Background: Melasma is an aesthetically undesirable skin condition which remains difficult to treat. Mulberry is a whitening agent with
antioxidant properties.
Objective: To evaluate the safety and efficacy of 75% mulberry extract oil as a treatment for melasma versus placebo.
Patients and Methods: 50 patients were recruited and randomly assigned into two groups, with 25 treated with 75% mulberry extract oil
and the other 25 treated with placebo. All patients had a negative repeat open application test (ROAT) to both mulberry extract and placebo.
Patients were followed up regularly at four-week intervals for a total of eight weeks [AUS: PLEASE REVIEW CHANGE FOR CONSISTENCY

Proof
WITH ‘MATERIALS AND METHODS’ SECTION]. The severity of the melasma was assessed using the melasma area and severity score
(MASI), Mexameter reading, melasma quality of life score (MelasQOL) and any adverse events noted.
Results: The mean MASI score significantly improved from 4.076 (±0.24) at baseline to 2.884 (±0.25) at week 8 for the 75% mulberry
extract oil group while the placebo group showed an improvement of a lesser magnitude. Mexameter readings for the mulberry group
showed a significant drop from 355.56 (±59.51) at baseline to 312.52 (±57.03) at week 8 compared to the placebo group, whose Mexame-
ter readings deteriorated from 368.24 (±46.62) at baseline to 372.12 (±44.47) at week 8. The MelasQOL score also improved tremendously
for the 75% mulberry extract oil group, falling from 58.84 (SD: ±3.18) at baseline to 44.16 (SD: ±4.29) at week 8, unlike the placebo group
that showed a less dramatic improvement from 57.44 (SD: ±4.66) at baseline to 54.28 (SD: ±4.79) at week 8. With regards to the adverse
events, only mild itching was reported in four patients from the 75% mulberry extract oil group while there were 12 cases of either itching
or erythema reported from the placebo group.

J Drugs Dermatol. 2011;10(9):xxx-xxx.

INTRODUCTION

M
elasma is an aesthetically undesirable hyperpig- cin, vitamin C, soy, arbutin, linoleic acid, burner root extract,
mentation that occurs mainly on the face, but can dithiaoctanediol, beta-carotene, scutellaria extract and mulberry
occur on any sun-exposed area.1 Melasma is mainly extract.6,9 Mulberry extract has been found to contain flavinoids
found in women of reproductive age.4 People with skin pho- and anti-oxidant properties.10 Its tyrosinase-inhibiting activity is
totypes III–V from regions of the world with intense sun expo- comparable to hydroquinone and kojic acid.9
sure are prone to developing melasma.2,3
The purpose of this study is to clinically evaluate the safety
Melasma can be difficult to treat, with most treatments beneficial and efficacy of mulberry extract oil as a skin lightening agent
only in the short-term and carrying associated adverse effects in the treatment of facial melasma. We sought to assess the
like irritation, contact dermatitis and leukoderma [AUS: PLEASE clinical response objectively by evaluating the melasma area
REVIEW CORRECTIONS TO SENTENCE].6 The current gold stan- and severity index (MASI), Mexameter readings, assessment
dard for treatment is hydroquinone.7 However, there have been by both the physician and a patient quality of life assessment
reports of contact dermatitis, nail bleaching and ochronosis.8 (MELASQOL) taken at baseline and during follow ups, and
Newer topical treatment options for melasma include lincomy- noting any adverse events.
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Journal of Drugs in Dermatology G Alvin, N. Catambay, A Vergara, et al.
September 2011 • Volume 10 • Issue 9

We sought to assess the clinical response or placebo (virgin coconut as base). The samples were placed in
identical pre-packed labeled bottles. The degree of hyperpigmen-
objectively by evaluating the melasma tation was determined using a Mexameter. Reading was taken

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area and severity index (MASI), from the face (cheeks, forehead and chin). The digital Mexameter
(Mexameter MX18, CK Electronic, Germany) provides an objective
Mexameter readings, assessment by both reproducible measurement of the two components of skin color,
the physician and a patient quality of erythema (hemoglobin) and melanin.The MASI score was created
by Kimbrough-Green to assess the area and severity of melas-
life assessment (MELASQOL) taken ma [AUS: PLEASE INCLUDE A REFERENCE FOR THIS]. Standard
at baseline and during follow ups, and photographs of the subjects were taken from the front, right and
left aspects of the face to highlight the hyperpigmented lesions.
noting any adverse events. The subjects were also interviewed by the clinical investigator re-
garding their quality of life since developing melasma, based on
the survey questions on the MelasQOL Score questionnaire. All
MATERIALS AND METHODS subjects were instructed to apply the topical oil twice-daily to the
The study was a randomized, single-blind, placebo-controlled, hyperpigmented lesions on the face. They were also given sun-
full-face, open 2-arm trial over a period of eight weeks, conducted block with SPF 30 which was to be applied to their whole face
on melasma subjects who voluntarily joined the study at the der- every morning 30 minutes after applying their designated topi-
matology outpatient department at a charity hospital in Manila. cal treatment. Subjects were advised to use an unscented soap to
wash the face and to avoid unnecessary sun exposure throughout
The protocol was submitted to the institutional Ethics Review the duration of the study. Subjects were followed up regularly at
Board and received its approval. An orientation of the research four-week intervals for a total of eight weeks.
team consisting of the principal researcher and two clinical inves-

Proof
tigators to the protocol was done before starting the study. The The mean change in MASI scores and Mexameter reading were
clinical investigators were responsible for screening the possible calculated using the Mann-Whitney test, while clinical scores be-
subjects and explaining the objectives of the study procedures, tween the treatment groups during follow ups were statistically
duration and the potential benefits and risks of participation. Writ- analyzed using the repeat manner ANOVA test. The percentage of
ten instruction and informed consent were obtained from each patients without adverse reaction was statistically calculated us-
of the patients [AUS: DID YOU MEAN WRITTEN INSTRUCTIONS ing the test of two proportions. Figure 1 shows a flow chart of the
WERE GIVEN TO EACH PATIENT? OBTAINED DOES NOT ENTIRE- methodology and data analysis for the study.
LY MAKE SENSE – IT IMPLIES THE PATIENTS THEMSELVES GAVE
INSTRUCTIONS FOR SOMETHING]. Each participant was assured FIGURE 1. Flow chart of the methodology and data analysis.
by the investigator that all information and results obtained from
Recruited subjects (n=50)
the study would remain strictly confidential. Subjects were free
to withdraw their participation from the study at any time. Any Woods Lamp assessment (min. 50% accentuation)
adverse effects from use of the treatment creams would be ap- ROAT ( 75% mulberry extract oil & placebo)

propriately treated and medication would be given free of charge.

BASELINE ASSESSMENT
Mexameter score MASI score MelasQOL score Photographs
Subjects were healthy adults of ages ranging between 18 to 60
years old, with modified Fitzpatrick skin phototpes III–V, had me- RANDOMIZATION
(COMPUTER PROGRAM)
lasma with an accentuation of at least 50 percent on Wood’s light
examination and were not hypersensitive to either mulberry ex-
tract or placebo. Exclusion criteria included: pregnant or nursing 75% Mulberry Extract Oil Group Placebo Group
(n=25) (n=25)
mothers; other pigmentary disorders; tretinoin, hydroquinone or
other bleaching cream or oral contraceptive use in the past six FOLLOW-UP SCHEDULE (WEEK 4 & WEEK 8)
months. All subjects enrolled had a negative repeat open allergy Mexameter score MASI score MelasQOL score Photographs
test (ROAT) to 75% mulberry extract oil and placebo.
COMPLETION OF STUDY
Fifty (50) adult patients (49 females, one male) were included in the (n=50)

study. A computerized randomization plan was used to randomly

DATA ANALYSIS
assign the patients to two groups: group A (75% mulberry oil ex-
(n=50)
tract) and group B (placebo). Subjects were randomly assigned to
apply either mulberry extract (75% mulberry in a coconut oil base) INTENTION TO TREAT ANALYSIS
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Journal of Drugs in Dermatology G Alvin, N. Catambay, A Vergara, et al.
September 2011 • Volume 10 • Issue 9

RESULTS treatment groups starting from baseline to week 8 using the

Demographic Data Repeated Measures ANOVA test within subjects showed pro-
The subject population consisted of 49 females (98.0%) and one gressive improvement for the 75% mulberry extract oil group

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male (2%) with ages ranging from a minimum of 25 years to a (P<0.05). The mean difference in MASI score from baseline to
maximum of 60 years old. The mean age of the study population week 8 for the 75% mulberry extract oil group was 1.19 while
was 44.5±7.5 years.The subjects were divided into two groups con- the placebo group had a mean difference of only 0.06 for the
sisting of 25 subjects. All of the 50 subjects completed the study. same period. Overall, there was a significant improvement in
the MASI score from baseline to week 8 for both [AUS: DID YOU
The mean age of subjects in group A was 46.6±8.4 years. The MEAN ‘BOTH GROUPS?’] the 75% mulberry extract oil group
mean age of subjects in group A was significantly older than the of subjects (P<0.05). Figure 3 shows a linear graph of the MASI
mean age of subjects in group B 42.4±6.0 (P value=0.031). Further scores from baseline to week 8 for the two groups.
statistical analysis using the Mann-Whitney test proved that the
comparison of the age distribution of subjects between the two Mexameter Reading
treatment groups was not statistically significant (P value=0.072). Mexameter reading at baseline exhibited a slightly lower val-
Figure 2 shows the age distribution of subjects in the two groups. ue for the 75% mulberry extract oil group (mean: 355.56, SD:
±59.51) compared to the placebo (mean: 368.24, SD: ±46.62)
With regards to the characteristics of melasma, the majority of but this difference was not statistically significant (P>0.05).
the subjects in both treatment groups had a centrofacial pattern, The computed mean Mexameter reading for the treatment
bilateral involvement, mixed type melasma with a 1–5 year dura- groups starting from baseline to week 8 demonstrated a
tion. Likewise, for both treatment groups, most of the subjects difference for the 75% mulberry extract oil group that was sig-
had no history of sun block use. Table 1 shows the detailed base- nificant (P<0.05) with decreased Mexameter values indicating
line characteristics of the subjects. a lightening of the pigmentation. The placebo group actually
showed a slight increase in Mexameter reading values. Figure

Proof
Results 4 shows a linear graph of the Mexameter reading from base-
Table 2 shows a comparison of the efficacy of 75% mulberry ex- line to week 8 for the two groups.
tract oil versus placebo as a topical treatment for melasma using
the MASI scores, Mexameter reading and MelasQOL score as Quality of Life Assessment
clinical parameters. Analysis of the MelasQOL data from the two treatment groups
using the Mann-Whitney test showed that at baseline, the 75%
MASI Score mulberry extract oil group had a MelasQOL score of 58.84 (SD:
The findings for MASI score using the Mann-Whitney test ±3.18) while the mean baseline MelasQOL score for the pla-
showed that the 75% mulberry extract oil had a slightly higher cebo group was 57.44 (SD: ±4.66); this difference between the
baseline value (mean: 4.076, SD: ±0.24) compared to the pla- two groups was found to be not statistically significant (P>0.05).
cebo group (mean: 3.484, SD: ±0.52) and this was statistically At week 8, the MelasQol score for the 75% mulberry extract oil
significant (P<0.05). The computed mean MASI score for the group improved to 44.16 (SD: ±4.29) while the placebo group’s
MelasQOL score was 54.28 (SD: ±4.79); this difference in the
FIGURE 2. Age distribution of subjects randomized to 75% mulberry MelasQOL score between the two groups was now significant
extract oil versus placebo. (P<0.05). The MelasQOL score pre- and post-treatment for the
two treatment groups showed a general improvement using the
Repeated Measures ANOVA test. Figure 5 shows a bar chart of
the MelasQOL scores from baseline to week 8 for the two groups.

Adverse Events
There were 16 reported cases of adverse events, four from
subjects in the 75% mulberry extract oil group and 12 from the
placebo group subjects. The complaints included erythema and
itching. At week 4, four cases in the 75% mulberry extract oil
group experienced a mild itching. In the control group, two cases
reported a mild pruritus and erythema at week 4, while anoth-
er two experienced a mild pruritus only. At week 8, there were
four reported cases of adverse effects, all from the subjects in
the control group. All four subjects had a mild pruritus, with two
reporting having mild erythema as well. None of the subjects de-
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Journal of Drugs in Dermatology G Alvin, N. Catambay, A Vergara, et al.
September 2011 • Volume 10 • Issue 9

TABLE 1.
Patient Demographics

Treatment Group
Subject Characteristic Total n=50 P value

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Mulberry group n=25 Placebo group n=25
Subject Characteristic Treatment Group Total 0 (0%) 0 (0%)
Age distribution, (%) 0.072
• 20–30 years 2 (8.0) 0 2
• 31–40 years 3 (12.0) 9 (36.0) 12
• 41–50 years 12 (48.0) 14 (56.0) 26
• 51–60 years 8 (32.0) 2 (8.0) 10
Gender distribution, (%)
• Female 25 (100.0) 24 (96.0) 49 1.00
• Male 0 1 (4.0) 1
Type of melasma, (%)
• Epidermal 2 (8.0) 1 (4.0) 3 0.500
• Mixed Type 23 (92.0) 24 (96.0) 47
• Dermal 0 0 0
Melasma pattern, (%)
• Malar 6 (24.0) 4 (16.0) 10 0.363
• Centrofacial 19 (76.0) 21 (84.0) 40
• Mandibular 0 0 0
Symmetry, (%)
• Bilateral 25 (100.0) 25 (100.0) 50 *
• Unilateral 0 0 0

Proof
Duration of melasma, (%)
• <1 Year 3 (12.0) 4 (16.0) 7 0.500
• 1–5 Years 22 (88.0) 21 (84.0) 43
• >5 Years 0 0 0
History of sun block use, (%)
• None 18 (72.0) 21 (84.0) 39 0.248
• With sun block use 7 (28.0) 4 (16.0) 11

veloped any serious adverse reactions that required treatment or

dropping out of the study. All the subjects that reported adverse DISCUSSION
events were able to complete the study successfully. Figure 6 Melasma is an acquired hyperpigmentation that occurs on
shows a photograph of one of the subjects in the study prior to sun-exposed skin, presenting as symmetrical, irregular, slowly-
applying the mulberry extract oil on her melasma and the same enlarging tan-brown macules and patches. Although the precise
subject at the end of the study. etiology of melasma remains unknown, it is said to be multi-
factorial.2 Genetic predisposition and sun exposure are major
FIGURE 3. MASI scores from baseline to week 8 for 75% mulberry factors in the development of melasma.2 Other factors include
extract oil group and placebo group. hormones, pregnancy, oral contraceptives and photosensi-
tizing medications, and certain cosmetics.2,4,5 The majority of
melasma cases occur in women, most commonly during their
reproductive years.4 People with brown skin types (Fitzpatrick
skin types IV to VI) from regions of the world with intense sun
exposure are more prone to developing melasma.2,3

The most common pattern of melasma is centrofacial, which

involves the cheeks, forehead, nose and chin, but it may also
present in a malar or mandibular distribution.2 Examination
using Wood's lamp will identify the depth of the melanin pig-
mentation, thus helping to determine the type of melasma,
which is classified into one of three histological types: epider-
mal, dermal and mixed.2
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Journal of Drugs in Dermatology G Alvin, N. Catambay, A Vergara, et al.
September 2011 • Volume 10 • Issue 9

FIGURE 4. Mean Mexameter reading from baseline to week 8 for 75% Demographics of our sample population were found to be
mulberry extract oil group and placebo group. similar to other reported literature on melasma in tropical re-
gions. The majority of our subjects were from the age group of

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41–50 years old. Their melasma was mainly of the mixed type
with a bilateral centrofacial pattern of distribution. The lesions
were found to have a duration of 1–5 years. Cestari et al. found
Brazilian women with melasma to have an average age of 42
years old and mainly skin phototypes III–V as well.11 Goh et al.
found Singaporean melasma subjects to have an average age
of 42 years. The subjects were of skin phototypes III–IV and had
melasma for an average duration of five years. The majority of
patients had a malar pattern of melasma of an epidermal type
on Wood’s lamp examination.12

Melasma is often progressive and recalcitrant to treatment

with hypopigmenting agents. Anecdotal studies with modali-
ties such as cryotherapy, medium-depth chemical peels and
lasers have shown them to be effective but they may have un-
predictable results and potential adverse effects that include
FIGURE 5. MelasQOL scores from baseline to week 8 for 75% mul-
local irritation, contact dermatitis, leukoderma and worsening
berry extract oil group and placebo group.
hyperpigmentation.6 The principles of melasma therapy include
protection from UV light, inhibition of melanocyte activity and
melanin synthesis, and the disruption and removal of melanin

Proof
granules.2 The gold standard in melasma treatment is topical
hydroquinone.7 However, reports of adverse reactions caused
by hydroquinone include irritant dermatitis, hyperpigmenta-
tion, ochronosis and nail bleaching.8

Amongst the new generation of therapeutic armamentar-

ium to overcome melasma are lincomycin, vitamin C, soy,
arbutin, linoleic acid, burner root extract, dithiaoctanediol,
beta-carotene, scutellaria extract and mulberry extract.6,9
Most of these are already being used as an adjuvant in skin
whitening products, but by themselves, they are yet to be
proven effective.9
FIGURE 6.
Mulberry extract is a natural potent antioxidant from the
Morus alba plant. Zhu et al. reported that mulberry is rich in
flavinoids, which act as a tyrosinase activity inhibitor.10 Ebanks
et al. showed that the flavinoids found in mulberry have a
structure similar to the dihydroxyphenyl group of DOPA, thus
enabling it to inhibit the activity of the tyrosinase enzyme at
the distal portion of the melanogenesis pathway.14 It was also
suggested that flavinoids have the capability to chelate copper
at the tyrosinase’s active site.14 Mulberry also contains mulber-
roside F, which has an inhibitory effect on tyrosinase activity
and also on melanin formation on melan-a cells.10 Studies by
Lee comparing the tyrosinase inhibition of mulberry revealed
that 0.39% concentration of mulberry extract inhibits tyrosi-
nase by 50 percent compared to 5.5 percent for hydroquinone
and 10.0 percent for kojic acid.10 Studies comparing the effects
of mulberry extract against kojic acid on the inhibition of ty-
rosinase activity have found mulberry extract to be 4.5 times
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Journal of Drugs in Dermatology G Alvin, N. Catambay, A Vergara, et al.
September 2011 • Volume 10 • Issue 9

TABLE 2.
Comparison of the Efficacy of 75% Mulberry Extract Oil Versus Placebo as a Topical Treatment for Melasma Among Using the MASI
Score, Mexameter Reading and MelasQOL Score
Treatment Group

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Subject Characteristic P value
Mulberry group n=25 Placebo group n=25
Masi Scores
• Baseline 4.076 (± 0.24) 3.484 (± 0.52) 0.000
• Week 4 3.296 (± 0.42) 3.456 (± 0.53) 0.496
• Week 8 2.884 (± 0.25) 3.392 (± 0.53) 0.000
P value** 0.000 0.000
Mexameter Reading
• Baseline 355.56 (± 59.51) 368.24 (± 46.62) 0.322
• Week 4 331.52 (± 56.13) 370.20 (± 44.23) 0.010
• Week 8 312.52 (± 57.03) 372.12 (± 44.47) 0.000
P value** 0.000 0.000
Quality of Life
• Baseline 58.84 (± 3.18) 57.44 (± 4.66) 0.310
• Week 8 44.16 (± 4.29) 54.28 (± 4.79) 0.000
P value** 0.000 0.000
*computed using Mann-Whitney test, significant at P<0.05.
**computed using Repeated Measures ANOVA.

more potent as a tyrosinase inhibitor.13 It was also discovered melasma. The authors recommend a larger sample size to
that mulberry had superoxide scavenging activity besides document efficacy of mulberry extract, and longer duration of

Proof
melanin synthesis inhibition and tyrosinase inhibition.13 treatment and follow-up to three or six months, as well as fol-
MASI and Mexameter reading scores in this study showed low up after the cessation of treatment for one month. Initial
a significant improvement for the mulberry extract oil group photopatch testing to rule out photocontact dermatitis should
compared to the placebo group, giving support to the above also be performed. A comparative study with 4% hydroqui-
data regarding mulberry extract as a lightening agent. The fact none, the gold standard for melasma, would be the next step
that the placebo group also exhibited an improvement in the in proving the worth of 75% mulberry extract oil as an effec-
MASI score may be due to diligent sunblock use.16 tive alternative for melasma treatment.

The MelasQOL scale was developed by Balkrishnan in 2003.11 DISCLOSURES

The quality of life domains found to be most affected by me- The authors have no relevant conflicts of interest to disclose
lasma were social life, recreation and leisure and emotional
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ADDRESS FOR CORRESPONDENCE

Maria Jasmin Jamora

1311 Batangas Street, Corner of Finlandia Street
Makati City, Philippines
Phone:………………….006328943952; 006322396098 [AUS: IS
THIS A TELEPHONE OR A FAX NUMBER?]
Fax:…………………...…..............................
E-mail:.…....……………[email protected]

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