# Efficacy and Tolerability of a Microneedling Device Plus Exosomes for Treating Melasma
## 4 Discussion  
Melasma is a challenging dermatological condition characterized by a tendency for recurrence and difficulties in achieving effective treatment. The condition entails both structural and functional alterations in the epidermis, basement membrane, and upper \begin{table}
\begin{tabular}{c c c c c} \hline \hline  & \multicolumn{2}{c}{**Much Improved**} & \multicolumn{2}{c}{**GAIS**} & \\  & & **4 (20\%)** & **Improved** & **No Change** \\  & & **14 (70\%)** & **2 (10\%)** \\ \hline \multirow{3}{*}{Age (yrs)} & 18–40 & 0 (0.0\%) & 1 (7.1\%) & 1 (50.0\%) \\  & 41–50 & 3 (75.0\%) & 5 (35.7\%) & 0 (0.0\%) \\  & 51–60 & 1 (25.0\%) & 4 (28.6\%) & 1 (50.0\%) \\  & \textgreater{}60 & 0 (0.0\%) & 4 (28.6\%) & 0 (0.0\%) \\ \hline \multirow{3}{*}{Sex} & Male & 1 (25.0\%) & 3 (25.0\%) & 0 (0.0\%) \\  & Female & 3 (75.0\%) & 11 (78.6\%) & 2 (100\%) \\ \hline \multirow{3}{*}{Fitzpatrick} & I & 0 (0.0\%) & 1 (7.1\%) & 0 (0.0\%) \\  & II & 4 (100\%) & 6 (42.9\%) & 2 (100\%) \\ \cline{1-1}  & III & 0 (0.0\%) & 7 (50.0\%) & 0 (0.0\%) \\ \hline \multirow{3}{*}{Number of} & 4 & 1 (25.0\%) & 4 (28.6\%) & 2 (100\%) \\ \cline{1-1}  & Sessions & 5 & 3 (75.0\%) & 10 (71.4\%) & 0 (0.0\%) \\ \hline \hline \end{tabular}
\end{table} 
Table 2: Percentage and number of subjects categorized based on GAIS score according to the baseline characteristics and total number of sessions. Figure 3: VECTRA evaluation of skin parameters (spots, wrinkles, texture and brown spots) at T0 (**A–D**) and T1 (**E–H**): A reduction in the percentage values related to all four analyzed parameters emerges; in particular, a significant improvement in spots and brown spots is observed. dermis, resulting in a distinctive hyper melanogenic phenotype. Current therapeutic approaches focus on reducing melanin production and inhibiting melanin synthesis pathways. However, the efficacy of most treatments is limited, and adverse effects are not uncommon [37]. Notably, the epidermal changes associated with melasma go beyond hypermelanosis. Recent histopathological studies have unveiled additional dimensions, exposing solar elastosis, a thinner SC, atrophic granular layer, and modifications in basal keratinocytes [5]. Sun exposure emerges as a pivotal environmental factor in melasma, with both UV and VL playing substantial roles in fostering melanin synthesis, activating tyrosine activity, and contributing to skin photoaging [7]. The increased vascularity, coupled with heightened VEGF expression, indicates angiogenic involvement in the pathogenesis of melasma. Perivascular mast cells and infiltrating leukocytes contribute to chronic skin inflammation, potentially influencing melanocyte activity and vascular changes [38]. Consequently, an effective therapeutic approach should not only address melanin production but also target the photoaging aspects of the skin. Originally developed in the 1990s for the treatment of scars, striae, and laxity [39], microneedling has evolved into a well-known procedure for effectively managing melasma. By creating controlled micro-injuries in the epidermis and papillary dermis, a complex local regenerative response is initiated. This encompasses the proliferation of keratinocytes, leading to an increased trans epidermal elimination of melanin, improvement in solar elastosis, and repair of the damaged basal membrane [40]. Furthermore, microneedling enhances the transcutaneous delivery of topical agents, creating microchannels that improves the penetration of active ingredients into the skin strata [41]. In fact, a substantial body of studies have evaluated its combination with topical or oral tranexamic acid, retinoic acid, and vitamin C, yielding encouraging results [10,42]. Due to its swift post-treatment recovery, minimal side effects, its safety in darker skin phototypes [43], and notable clinical outcomes, microneedling stands as a valuable alternative to more invasive approaches like laser skin resurfacing and deep chemical peeling [44].