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Article

Comparative Study of Azelaic Acid Peeling vs. Tranexamic Acid Microneedling for the Treatment of Melasma

by
Guilherme dos Anjos Camargo
1,
Daniella Woinarovicz Menegheti
1,
Leticia Simeoni Avais
2,
Evelyn Assis de Andrade
3,
Patrícia Mathias Döll Boscardin
1 and
Giovani Marino Favero
1,*
1
Postgraduate Program in Pharmaceutical Sciences, State University of Ponta Grossa, Ponta Grossa 84030-900, Paraná, Brazil
2
Postgraduate Program in Dentistry, State University of Ponta Grossa, Ponta Grossa 84030-900, Paraná, Brazil
3
São Carlos Institute of Chemistry, University of São Paulo, São Carlos 13560-970, São Paulo, Brazil
*
Author to whom correspondence should be addressed.
Dermato 2025, 5(3), 16; https://doi.org/10.3390/dermato5030016
Submission received: 14 May 2025 / Revised: 8 July 2025 / Accepted: 22 August 2025 / Published: 4 September 2025
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Abstract

Melasma is an acquired hyperpigmentation that is more common in women and mainly affects the face. It can significantly reduce quality of life due to its chronic nature and resistance to treatment. Objectives: This study aimed to compare the clinical efficacy of azelaic acid peeling and combined tranexamic acid microneedling in patients with melasma, evaluating the impact of these therapies on skin depigmentation. Methods: This was a prospective clinical trial with a split-face design, using a convenience sample. Patients were recruited and divided into two groups for comparative treatment. Microneedling with 4 mg/mL tranexamic acid was applied to the right hemiface and 30% azelaic acid peeling to the left hemiface. The protocol included five sessions with a 15-day interval. Photographic records were taken before treatment, in the fifth session, and 15 days after the last session. The Melasma Area and Severity Index (MASI) and non-parametric tests were used to analyze the results. Results: The study included 10 patients, of whom 9 completed the treatment. The average age was 42 years. The most common skin phototype was type III (50%) and the predominant locations were the central facial area, forehead, and cheeks (55.6%). The photographic evaluation and MASI showed a significant improvement on both sides of the face, with the final values better than the initial ones. It was possible to observe that the azelaic acid peeling showed a significant whitening after the fourth session when compared to the other method. Conclusions: The clinical study of hemifaces concluded that both the azelaic acid peeling and microneedling with tranexamic acid are effective in the treatment of melasma, with the azelaic acid peeling showing results after the fourth session. Further studies with larger, randomized samples are recommended.

Graphical Abstract

1. Introduction

The skin plays the primary role of protecting the body from the influences of the external environment, preventing the entry of potentially harmful substances. It is organized into three distinct layers, with the epidermis being the outermost and main protective barrier. The intermediate layer, the dermis, is vascularized and contains structures essential for the function of the skin, while the hypodermis, the deepest layer, is composed predominantly of adipose tissue [1].
Melasma is an acquired hyperpigmentation of brown or grayish-brown coloration that occurs most frequently on the skin of the face and occasionally on the neck and forearms [2], affecting approximately 30% of women of childbearing age in certain populations [3]. It is a dermatological condition that can be easily diagnosed through clinical evaluation. However, it is characterized by a chronic nature, significant resistance to available treatments, and recurrent episodes [4].
Melasma has a significant detrimental effect on health-related quality of life (HRQoL) due to its complexity and location. Research indicates that individuals affected by this disorder often report low self-esteem, avoid outdoor activities, and experience frustration with expensive and limited-effectiveness treatments [5,6].
According to Abdalla (2021) [7], melasma is classified into four distinct types: (1) Epidermal, characterized by increased pigment deposition in the epidermis; (2) dermal, defined by the accumulation of melanin around blood vessels, both superficial and deep; (3) mixed, in which excess pigment is present simultaneously in the epidermis and dermis, affecting different areas of the skin; and (4) indetermined form. In addition to these classifications, melasma often manifests in three main facial regions: the symmetrical malar region, the centrofacial region, and the mandibular region.
The condition known as melasma is characterized by abnormalities in skin pigmentation. Initially, an increased proliferation of melanocytes is observed, increasing in number. Subsequently, these melanocytes increase in volume and exhibit a greater arborization of their dendrites, which promotes an increased transfer of melanosomes to the basal and suprabasal layers of the epidermis [8].
The main etiological factors associated with melasma include genetic predisposition and exposure to sunlight. In addition, high levels of melanocyte-stimulating hormone (MSH), the use of photosensitizing medications or cosmetics, racial characteristics, and endocrine disorders also play significant roles in its occurrence [7,9]. Therefore, the main objective of melasma treatment is to lighten the affected areas, and the main therapeutic options include chemical peels, microneedling, lasers, bleaching agents, and pulsed light [10]. Melasma treatment is difficult and relapses often occur, and most treatments aim to decrease melanogenesis and the depth of melanocyte invasion [11].
The therapeutic approach employed through the use of chemical peeling, also known as chemoexfoliation, essentially consists of the topical application of an acidic agent on the skin, aiming at the controlled removal of its layers, followed by a regenerative process that culminates in aesthetic improvement [12]. Peelings can be classified based on the depth of penetration, being divided into three categories: superficial peelings, which remove the stratum corneum; medium peelings, which reach the papillary dermis; and deep peelings, which affect the middle reticular dermis. The depth of the peeling is directly related to the results obtained: deeper procedures tend to generate more significant effects but also increase the risk of discomfort during the post-procedure period [13].
The microneedling technique consists of making multiple perforations in the epidermis and dermis using devices equipped with microneedles. Its application is widely recognized in the treatment of skin sagging, promoting the stimulation of neocollagenesis through the activation of fibroblasts. Recently, this approach has also been associated with lightening effects and is generally recommended for persistent cases of melasma, where its mechanism of action in this condition is not yet fully understood. However, studies indicate that its use alone or in combination with the delivery of lightening substances has shown satisfactory results [14].
Tranexamic acid (TXA) acts as an antifibrinolytic agent by blocking the conversion of plasminogen to plasmin, a crucial enzyme in melanogenesis. By inhibiting this enzymatic conversion, tranexamic acid reduces the hyperpigmentation associated with melasma by inhibiting melanin synthesis and interfering with the interaction between keratinocytes and melanocytes. Its effects on the plasminogen–plasmin pathway play a significant role in this process. Furthermore, tranexamic acid is effective in modulating the vascular components of melasma [15].
Azelaic acid (AZA) is a naturally occurring, non-phenolic, saturated, nine-carbon dicarboxylic compound obtained from cultures of the yeast Malassezia. Originally developed for the treatment of topical acne, AZA has gained additional application due to its inhibitory capacity on tyrosinase, and this property has led to its use in the treatment of conditions such as melasma and post-inflammatory hyperpigmentation (PIH) [16].
Therefore, this study aimed to compare and evaluate the clinical efficacy and depigmentation speed of azelaic acid peeling in contrast to the efficacy of microneedling associated with tranexamic acid solution in female patients with melasma. We used the MASI evaluation method and applied the Friedman test, a nonparametric test for paired data.

2. Materials and Methods

The study was submitted for review and approval by the Research Ethics Committee of the State University of Ponta Grossa (UEPG) under number 6.598.206. The clinical trial included the participation of 10 volunteers, among them employees of the Ponta Grossa State University and external participants from the institution, all over 30 years old. This sample was selected through a convenience sampling strategy. All patients were informed about the study, agreed, and signed the Informed Consent Form (ICF) and Image Authorization Form. Before the start of the study, a preliminary anamnesis was performed on all volunteers to verify their skin phototypes and locations of melasma. The exclusion criteria for the study were patients under 18 years old, pregnant and lactating women, patients with hypersensitivity to the formulas, and a history of keloids.
The patients were recruited and assessed for the need for treatment using the Wood’s Lamp (Beauty Star Woods Lamp Skin Analyzer, Professional Esthetician Supplies, Shenzhen, China). Subsequently, photographs of the participants were taken using the Wood’s Lamp and a 12-megapixel digital camera, 13 mm, f/2.4 aperture, and 120° viewing angle (iPhone® 14), to compare the results obtained before and after the treatment.
Different treatments were applied to the right and left hemiface of the patients to allow a direct comparison of the treatments’ efficacy (Figure 1), according to the method adapted from Agostinho et al., 2019 [17].
First, the patients’ skin was cleansed with a 5% glycolic acid foam followed by the application of 70% alcohol to remove skin oil. Subsequently, 2 mL of a sterile tranexamic acid solution at a concentration of 4 mg/mL (PHD do Brasil® 001-11886) was applied to the right hemiface. The acid was microneedled into the skin at a depth of 0.5 mm using a microneedling pen (Smart Dermapen SP01 Electric Microneedling Pen–Gr Med Produtos Médicos e Hospitalares LTDA–Serial Number: 23-A-0477, São Paulo, Brazil) with a cartridge (Smart Derma Pen HK Cartridge–36 needles–Smart GR, ANVISA: 81382050027, São Paulo, Brazil). At the end, the patient was instructed to cleanse the treated area with neutral liquid soap after 24 h and apply sunscreen regularly. Each cartridge containing 36 needles was used individually and only once, being discarded immediately after the session.
On the left hemiface, a 30% azelaic acid peel in cream form was applied topically, removed after 4 h with neutral soap and running water, and sunscreen was also applied regularly.
Each patient underwent a total of five sessions, each spaced 15 days apart, with photographic records taken before the start of treatment, after the fourth session, and 15 days after the final session. Subsequently, the photographs were analyzed and classified based on the lightening of the spots.
The Melasma Area and Severity Index (MASI) (Figure 2) was used to classify the extent and severity of the patients’ melasma. For this index, three main factors were considered: area of involvement (A), darkness (D), and homogeneity (H).
For the evaluation, the face was divided into four specific areas (Table 1) [17].
In the evaluation of the area of involvement, each of the four facial regions was classified on a scale of 0 to 6 (Table 2) [17].
Darkness and homogeneity were evaluated on a scale of 0 to 4 (Table 3) [17].
The total MASI score was obtained by multiplying the area involvement score of each facial region by the corresponding darkness score and adding the values for homogeneity, with the total score ranging from 0 to 48 [17]. For the data analysis, nonparametric statistical tests were applied. The Friedman test for paired data was used to compare scores between different sessions [18], while the Wilcoxon test was used to compare scores between two sessions or between different facial regions within a single session [19]. The Nemenyi test was applied as a post-hoc test for multiple comparisons after the Friedman test [20]. The analyses were adjusted by the single-step method and performed using the jamovi software version 2.4 [21].

3. Results

For the study, 10 patients were selected, of which only 9 completed the treatment. One participant did not complete the study due to repeated absence from treatment sessions, which made it impossible to continue with the protocol. The average age of the patients was 42 years, ranging from 32 to 71 years. The most prevalent skin phototype was type III, representing 50% of the group, and the most common melasma location was the centrofacial region (55.6%). Regarding the origin of melasma, 22% of the patients reported it appeared after pregnancy, 22% after the use of oral contraceptives, and 56% could not identify a specific factor. Half of the patients had previously undergone treatments for melasma, while the other half had never received any treatment.
In the photographic evaluation, a significant improvement was observed on both sides of the patients’ faces, as exemplified in Figure 3 and Figure 4.
Regarding the results obtained through the MASI (Figure 5, and Table 4), a significant improvement was observed on both sides of the face, as the initial score values were higher than the final ones.
In the Right Region, scores between sessions 1 and 5 showed significant differences (p < 0.001). Similarly, in the Left Region, significant differences were observed in scores among sessions 1, 4, and 5 (p < 0.001). The Forehead Region also exhibited differences among sessions 1, 4, and 5 (p = 0.009). In contrast, no significant differences were found in the Chin Region (p = 0.367).
Wilcoxon tests were employed to compare the scores between the right and left regions in each session. No statistically significant differences (p = 0.368) in scores between the right and left regions in any of the analyzed sessions were observed (1st, 4th, and 5th sessions) (Table 5).
In other words, the intervention applied to the right hemiface (microneedling with tranexamic acid) shows results comparable to the intervention on the left hemiface. However, it was observed that the substance applied to the left region (azelaic acid peel) showed a significant difference after the fourth session (p < 0.001), whereas the right region demonstrated a change only in the fifth and final session.

4. Discussion

The results demonstrate a significant improvement in patients who underwent treatment, highlighting a positive response to the applied approaches. Photographic image analysis revealed a notable difference in pigmentation on both sides of the face. AZA peeling stands out as an effective approach due to its anti-inflammatory properties and its ability to inhibit tyrosinase, a key enzyme in melanin synthesis [22,23,24]. This procedure promotes mild exfoliation of the skin, reducing pigmented superficial layers while improving overall texture and tone. Furthermore, AZA is well tolerated, making it suitable for patients with different skin types [25].
Microneedling combined with ATX is a technique that enhances the lightening of hyperpigmented areas by inducing microlesions in the skin, stimulating cell regeneration, and increasing the penetration of depigmenting agents. ATX, known for its inhibitory effects on the plasminogen–keratinocyte system, reduces inflammation and vascularization, both of which contribute to melasma formation [26]. When applied immediately after microneedling, its efficacy is enhanced due to increased absorption through the microlesions in the skin barrier [27].
The Fitzpatrick classification [28] was employed at the beginning of the study as a key criterion for participant selection. This classification is widely used to categorize skin types and is particularly relevant to the study’s objective of improving skin pigmentation. Epidermal pigmentation variations were more clearly visible under the Wood’s lamp, whereas dermal changes were less evident or even absent when compared to observations under visible light [29]. The Wood’s lamp is a widely used tool for assessing skin lesions, enabling the analysis of their characteristics and extent through fluorescence emitted when the lesion is exposed to short-wavelength ultraviolet light. This method is extensively utilized in melasma classification, providing valuable insights for the diagnosis and treatment of this condition [30].
In line with the findings observed in the patients, the present study applied five sessions of microneedling combined with ATX drug delivery, resulting in a 40.8% clinical improvement in the MASI index when comparing baseline and final values. Budamakuntla et al. (2013) [31] conducted a randomized clinical trial with 60 patients with moderate to severe melasma, divided into two groups of 30 patients each. The first group received three sessions of ATX microinjections at monthly intervals, while the second group underwent the same number of microneedling sessions followed by ATX drug delivery. In the group that received microinjections, a 38% improvement in the MASI index was observed, whereas the microneedling group showed a 44% improvement. The authors attributed the superior results in the combined therapy group to the greater dermal availability of the active ingredient provided by the microchannels created by microneedling.
The efficacy of the treatments was compared based on various aspects, including MASI progression, which is a metric for evaluating melasma. This index has been widely used in the literature to assess treatment response for the condition [32].
ATX can be considered a promising, safe, and effective therapeutic agent for melasma treatment. It is worth highlighting that this acid is widely available, provides relatively rapid results, and has a minimal side effect profile with no downtime. Among the adverse effects of topical ATX we can highlight irritation, erythema, scaling, xerosis, itching, and burning [31,33].
Meanwhile, the left hemiface, treated with 30% AZA peeling, showed a 53.39% reduction in the MASI index when comparing first to fourth treatments. A comparative study between 20% AZA and 4% hydroquinone revealed that pigmentation was significantly reduced with AZA use after two months of treatment, as assessed via the MASI index. AZA resulted in a 50% reduction in the MASI score, whereas hydroquinone achieved only a 14% reduction [34]. Studies have demonstrated that AZA can inhibit tyrosinase activity, reduce the formation of abnormal melanocytes, and exhibit anti-inflammatory properties. These effects make it a promising alternative for melasma therapy [35].
The absorption of drugs through the skin is modulated by several factors, including epidermal thickness, hair follicle density, sun exposure level, sex, skin phototype, epidermal barrier integrity, and prior skin preparation. The efficacy of drug application is influenced by pre-application skin cleansing, recent prior interventions, the physicochemical properties of the drug, as well as the volume and concentration of the agent, the vehicle used, exposure time, application method, occlusion presence in the treated area, pressure and friction during application, number of applied layers, and frequency of procedures [36,37]. These variables are critical in determining treatment success and effectiveness.
Despite the availability of various therapeutic options, achieving complete melasma control and maintaining long-term remission remain significant challenges. Regarding topical treatment modalities, a wide range of depigmenting agents is available, and evidence suggests that combining these agents may increase the likelihood of successful treatment [38].
Given that melasma is a chronic condition, often resistant to treatment and with a potential stigmatizing impact, the findings of the present study indicate that both AZA peeling and microneedling with ATX are effective treatment options. Understanding their mechanisms of action, it can be suggested that the hemiface treated with AZA peeling achieved effective epidermal melasma lightening, as this peeling does not reach deeper skin layers. Meanwhile, the hemiface treated with microneedling and ATX may have addressed both epidermal and dermal melasma, as the microperforations created in the patients’ skin can enhance deeper ATX penetration, thereby increasing its efficacy for both melasma types.
The synergy between these treatments yields remarkable results. While AZA peeling reduces superficial pigmentation, microneedling with ATX acts at a deeper level, promoting progressive and long-lasting lightening. This combined approach also minimizes side effects and reduces the risk of post-inflammatory hyperpigmentation, a common challenge in melasma treatment. However, additional clinical studies are needed to validate these findings.
Ultimately, melasma treatment often leads to dissatisfaction due to the high recurrence rate of lesions and the lack of definitive depigmentation alternatives. Controlled clinical studies suggest that photoprotection and the use of depigmenting agents are the first-line recommended approaches for treating this condition [39,40]. However, combining aesthetic procedures with broad-spectrum sunscreen—covering both UVA and UVB—as well as topically applied and orally administered depigmenting agents is also essential for effective treatment [41,42].
Therefore, it is crucial to emphasize that the success of these treatments depends on the consistent use of sunscreen and complementary skincare measures. Additionally, a prior dermatological evaluation is essential to tailor the approach according to each patient’s characteristics. Although melasma is often viewed solely as a cosmetic concern, its impact can be profound, significantly affecting individuals’ social, family, and professional lives, leading to psychological effects that should not be underestimated [6,43,44].
Furthermore, this prospective comparative study contributes to the clinical understanding of melasma treatment by directly comparing azelaic acid chemical peeling with tranexamic acid delivered via microneedling. While both groups showed promising outcomes, we acknowledge key limitations, including the relatively small sample size, the lack of long-term follow-up to assess the durability of the response, and the absence of instrumental or histological methods to deepen the clinical findings. As this was a pilot study conducted with a convenience sample, no a priori power calculation was performed. This is consistent with the exploratory nature of the study, which aimed to observe clinical trends and generate hypotheses rather than to provide definitive statistical inferences. The small number of participants inevitably limits the generalizability of the findings and the statistical power to detect subtle differences. Therefore, future studies with larger sample sizes, extended follow-up periods, and the use of advanced imaging or histopathological techniques are warranted to confirm and expand upon the present results.

5. Conclusions

This clinical hemiface study demonstrated that both azelaic acid peeling and microneedling with tranexamic acid are effective treatment modalities for melasma. No statistically significant differences were found between the right and left facial regions at any time point, according to the Wilcoxon test, indicating that both interventions contributed to skin lightening. However, azelaic acid at 30% concentration showed earlier clinical effects, with noticeable improvements from the fourth session onward, while tranexamic acid via microneedling produced visible results after the fifth session. To our knowledge, this is the first study to directly compare these two techniques, contributing valuable preliminary evidence to the clinical management of melasma.

Author Contributions

Conceptualization, G.d.A.C. and D.W.M.; methodology, D.W.M.; software, L.S.A.; validation, G.d.A.C. and P.M.D.B.; formal analysis, G.d.A.C. and E.A.d.A.; investigation, G.d.A.C. and D.W.M.; resources, G.d.A.C. and G.M.F.; data curation, G.d.A.C.; writing—original draft preparation, G.d.A.C. and D.W.M.; writing—review and editing, G.d.A.C., L.S.A. and E.A.d.A.; visualization, G.d.A.C.; supervision, G.M.F.; project administration, G.M.F.; funding acquisition, G.d.A.C. and G.M.F. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the State University of Ponta Grossa (protocol code 6.598.206 and December 21st, 2023).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patient(s) to publish this paper.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Representation of the methodology applied to the left and right hemiface.
Figure 1. Representation of the methodology applied to the left and right hemiface.
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Figure 2. Melasma Area and Severity Index (MASI).
Figure 2. Melasma Area and Severity Index (MASI).
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Figure 3. Comparative results of two representative cases, obtained through the photographic evaluation of patients before and after five sessions of azelaic acid peeling and microneedling with tranexamic acid.
Figure 3. Comparative results of two representative cases, obtained through the photographic evaluation of patients before and after five sessions of azelaic acid peeling and microneedling with tranexamic acid.
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Figure 4. Comparison of hemifaces through photographic evaluations using Wood’s light before and after five sessions of azelaic acid peeling combined with microneedling with tranexamic acid.
Figure 4. Comparison of hemifaces through photographic evaluations using Wood’s light before and after five sessions of azelaic acid peeling combined with microneedling with tranexamic acid.
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Figure 5. Relationship of MASI score results for both sides of the face, indicating the average of the 1st, 4th, and 5th sessions.
Figure 5. Relationship of MASI score results for both sides of the face, indicating the average of the 1st, 4th, and 5th sessions.
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Table 1. Regions of the face evaluated for MASI.
Table 1. Regions of the face evaluated for MASI.
Forehead (F)30%
Right malar region (RM)30%
Left malar region (LM)30%
Chin (C)10%
Table 2. Evaluation of the area of involvement.
Table 2. Evaluation of the area of involvement.
0No involvement
1<10%
210–29%
330–49%
450–69%
570–89%
690–100%
Table 3. Evaluation of the darkness and homogeneity.
Table 3. Evaluation of the darkness and homogeneity.
0Absent
1Slight/Weak
2Mild/Gentle
3Marked
4Maximum
Table 4. The average MASI values for 1st, 4th, and 5th sessions of the 9 patients on the right side (RS) and left side (LS) of the hemiface.
Table 4. The average MASI values for 1st, 4th, and 5th sessions of the 9 patients on the right side (RS) and left side (LS) of the hemiface.
Patient1st RS1st LS4th RS4th LS5th RS5th LS
14.84.83.61.83.61.8
25.45.42.43.61.21.8
36.06.04.84.83.63.6
45.45.43.63.63.01.8
52.43.62.41.81.81.2
61.81.21.21.20.60.6
73.61.33.61.23.01.2
83.69.03.64.52.44.5
94.53.02.62.42.42.4
Table 5. Nemenyi Test Results for Multiple Comparisons.
Table 5. Nemenyi Test Results for Multiple Comparisons.
Comparison Right Sidep-Value
Session 4–Session 10.2759
Session 5–Session 10.0018 **
Session 5–Session 40.1428
Comparison Left Sidep-Value
Session 4–Session 10.0483 *
Session 5–Session 10.0008 ***
Session 5–Session 40.3972
Note: p-values indicate the level of statistical significance for the comparisons performed. Asterisks denote significance levels as follows: p * < 0.05: statistically significant; p ** < 0.01: highly significant; p *** < 0.001: very highly significant.
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MDPI and ACS Style

dos Anjos Camargo, G.; Menegheti, D.W.; Simeoni Avais, L.; de Andrade, E.A.; Döll Boscardin, P.M.; Favero, G.M. Comparative Study of Azelaic Acid Peeling vs. Tranexamic Acid Microneedling for the Treatment of Melasma. Dermato 2025, 5, 16. https://doi.org/10.3390/dermato5030016

AMA Style

dos Anjos Camargo G, Menegheti DW, Simeoni Avais L, de Andrade EA, Döll Boscardin PM, Favero GM. Comparative Study of Azelaic Acid Peeling vs. Tranexamic Acid Microneedling for the Treatment of Melasma. Dermato. 2025; 5(3):16. https://doi.org/10.3390/dermato5030016

Chicago/Turabian Style

dos Anjos Camargo, Guilherme, Daniella Woinarovicz Menegheti, Leticia Simeoni Avais, Evelyn Assis de Andrade, Patrícia Mathias Döll Boscardin, and Giovani Marino Favero. 2025. "Comparative Study of Azelaic Acid Peeling vs. Tranexamic Acid Microneedling for the Treatment of Melasma" Dermato 5, no. 3: 16. https://doi.org/10.3390/dermato5030016

APA Style

dos Anjos Camargo, G., Menegheti, D. W., Simeoni Avais, L., de Andrade, E. A., Döll Boscardin, P. M., & Favero, G. M. (2025). Comparative Study of Azelaic Acid Peeling vs. Tranexamic Acid Microneedling for the Treatment of Melasma. Dermato, 5(3), 16. https://doi.org/10.3390/dermato5030016

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