Subjects were monitored by the investigator during the study for the development of adverse reactions eg, erythema, itching, sensation, dryness. One subject experienced mild erythema of the whole face on Days 2 and 3. However, the erythema had disappeared by Day 4 without the need to discontinue the application of both lotions. No adverse reactions related to GSSG were reported during the study period.
All subjects tolerated the GSSG lotion well and reported no untoward symptoms. Baseline characteristics of subjects The baseline characteristics of the 30 female subjects are shown in Table 2. Mean age was In contrast, sites that received GSSG lotion showed a clear decrease in melanin index values, beginning in the early weeks of the study period Week 0: From Weeks 1 through 10, the melanin index values of the sites that received GSSG lotion were significantly lower than the values of the sites that received placebo lotion.
P-values were calculated by using the Wilcoxon signed-rank test. Abbreviation: GSSG, oxidized glutathione. Curvature index values and keratin index values calculated by SkinSys software analysis are shown in Figure 3B. The curvature index values were significantly lower at GSSG sites than at placebo sites in Weeks 6 and However, the elasticity index values measured with the Triplesense TR-3 did not differ significantly between the sites that received GSSG and those that received placebo data not shown.
Figure 3 Moisture index, curvature index, and keratin index results during intervention. Scores of 2 or more were indicative of skin benefits assessed as visibly significant by both the investigator and the subjects. In contrast, a skin-whitening score of 2 was received by However, a wrinkle-reduction score of 2 was received by 3. Table 3 Beneficial effects of GSSG treatment of skin, as scored by investigator and subjects Note: Data are expressed as percentages of the total number of subjects.
In contrast, None of the subjects reported wrinkle reduction at placebo sites. However, 3. Discussion We evaluated the effects of the topical application of a lotion containing GSSG to the face for 10 weeks. We used the melanin index value, which reflects the skin melanin content, as an objective outcome indicator, and we added subjective assessments by the investigator and by study participants. These evaluations revealed the positive effects of GSSG lotion, suggesting that its topical use effectively whitens skin.
Melanin in human skin is a polymer of various indole compounds synthesized from L-tyrosine. Two different types of melanin — eumelanin, which is black or brown, and pheomelanin, which is yellow-red — are found in human skin, and the ratio of these two complex polymers determines skin color. Melanin production is induced after exposure to UV radiation and plays a key role in protecting the skin cells from UV radiation damage.
However, melanin pigmentation in the epidermis causes skin changes such as sun tanning and mottled pigmentation. The presence and enzymatic activities of glutathione reductase and glutathione peroxidase in the human dermis and epidermis have been demonstrated before. Therefore, we can assume that a fraction of the GSSG applied to the skin is converted to GSH and acts on melanocytes in the epidermis, thus whitening the skin.
The mechanisms by which GSH inhibits melanogenesis have been studied well in vitro. One mechanism is the inhibition of tyrosinase activity; this is a well-known function of thiol compounds in general, including GSH and cysteine. Like GSH, kojic acid, arbutin, and hydroquinone currently commonly used to whiten skin, have inhibitory effects on tyrosinase.
Another mechanism for the skin whitening effect of GSH is activation of the pheomelanin pathway. Synthesis of pheomelanin starts with the conjugation of L-dopaquinone formed from L-tyrosine with cysteine. This reaction yields the pheomelanin precursor cysteinyldopa. GSH can also conjugate L-dopaquinone in the presence of glutathione S-transferase and yield glutathionyldopa, a precursor of cysteinyldopa. As a result, cysteinyldopa synthesis is induced, leading to increased production of pheomelanin, which is yellow-red.
However, we have a preliminary result: the minimal erythemal dose of GSSG was significantly increased by its application to the UV-irradiated skin of hairless mice data not shown. This finding suggests that the topical effect of GSSG on the inflammatory response occurs via UV-induced oxidative stress. We therefore speculate that there is a relationship between GSSG skin-whitening efficacy and oxidative stress.
Taking all of these findings into account, the inhibitory action of GSH on melanogenesis is evident. Moreover, oral intake of GSH enhances skin whitening in human subjects when melanin index values, reflecting melanogenesis inhibition as an outcome indicator, are used. Arjinpathana and Asawanonda found that healthy medical students who took mg of GSH orally twice daily for 4 weeks had significantly lower melanin index values as measured on the cheek and on the sun-exposed forearm than those who received placebo.
The above-mentioned mechanism of the skin-whitening efficacy of topical GSSG and its relationship to GSH are not clear and are no more than speculation. This is a limitation of our study, and the mechanism by which topical GSSG whitens skin effectively will have to be revealed by further studies. Our study showed that topical application of GSSG lotion effectively reduced wrinkle formation in both objective and subjective evaluation tests. Furthermore, in our objective evaluation, skin moisture levels were significantly higher at sites that received GSSG lotion than in those that received placebo, indicating the moisturizing effect of GSSG.
However, in the objective evaluations the degree of change except for melanin index value was not large. One reason for this may be that the subject selection criteria in relation to skin condition included only the melanin index value, an indicator of skin whitening.
Inclusion of selection criteria that reflect skin conditions other than skin whitening would be more suitable for evaluating each skin condition. Defective wound healing in patients with diabetes results from dysfunction of skin fibroblasts and epidermal keratinocytes; this dysfunction is related to the disruption of intracellular GSH homeostasis. Deveci et al showed that GSH enhances collagen contraction in human dermal fibroblasts and protects the keratinocytes from apoptosis under hyperglycemic conditions.
In conclusion, our study indicates that GSSG is a potent agent that can promote skin whitening and improve skin condition. It is difficult to evaluate the effect of GSH in topical aqueous solution because of its instability. The skin-whitening effect observed here in healthy females after GSSG application represents an important, novel finding. Our clinical trial was conducted in the Philippines, which has a tropical climate.
Subjects were advised to avoid applying sunscreen. The principal site of absorption is the upper jejunum. Circulating glutathione is primarily cleared by the kidney. This is based on the observation of lack of similar increase in plasma glutathione levels after the administration of the constituent amino acids of glutathione when compared to the administration of glutathione capsules.
The administration of cysteine-rich glutathione precursors, especially N-acetyl cysteine, has been shown to increase intracellular glutathione levels. A single-dose study conducted by Witschi et al. This results in increased hydrolysis of glutathione with resultant low serum levels.
Results showed a steady increase in glutathione levels when compared to the baseline. The raised levels returned to baseline after a one-month washout period. In summary, human trials performed before have shown that over-the-counter oral glutathione supplementation has a negligible effect on raising plasma levels in humans.
The only trials that support the concept of oral supplementation to raise glutathione levels in healthy adults have been conducted by Richie et al.
It is important to take note of the fact that both studies used a specific brand of glutathione, manufactured by the trial funding company. Oral formulations of glutathione: Manufacturing and processing issues Manufacturing high dose glutathione pills is technically difficult as GSH has a very high electrostatic charge which makes processing and encapsulating higher strengths of glutathione very difficult.
Alpha lipoic acid is a glutathione replenishing disulfide that increases whole blood and intracellular GSH levels. Oral glutathione is also available as sublingual tablets and solutions. While sublingual preparations contain very low doses 50— mg , oral suspensions and solutions have a foul sulfurous taste and need to be freshly prepared. This has recently become available over-the-counter in India as well.
Evidence-based efficacy of glutathione as an oral-lightening agent On review of literature, we could find only two studies that evaluated the efficacy of oral glutathione as a skin-lightening agent. A randomized, double-blind, two-arm, placebo-controlled study conducted in the Thai population studied the effect of orally administered glutathione on the skin melanin index in sixty healthy medical students [Table 1].
The primary end-point studied was the reduction of melanin indices at six different sites. At four weeks, the melanin indices decreased consistently at all six sites in the glutathione group. There was a statistically significant reduction at two sites in the placebo group, namely the right side of the face and the sun-exposed left forearm.
The tolerance to glutathione was excellent. The limitations of this study include a short study period, lack of follow-up, lack of measurement of serum glutathione levels and the choice of cohort, which consisted of a young and healthy population. Despite these shortcomings, this study was the first to demonstrate the beneficial effects of oral glutathione in skin lightening. In our opinion, the sublingual or buccal route is likely to increase the bioavailability of glutathione better than oral tablets or capsules.
A comparative study between these two routes of administration is the only way to provide reliable evidence in this regard. Interestingly, intravenous injections of glutathione have been used for years but there is not even a single clinical trial evaluating its efficacy.
Manufacturers of intravenous glutathione injections recommend a dose of — mg for skin lightening, to be injected once to twice weekly. The duration for which they should be continued is not specified. However, there are no studies to support this hypothesis.
Although intravenous glutathione delivers a much higher therapeutic dose that enhances its efficacy, it also provides a narrower margin of safety due to the possibility of overdose toxicity. There is no available data on the efficacy of intravenous glutathione for skin lightening. The data on safety are available, but scarce.
In an animal-based study, no significant adverse effects were reported in dogs, who were administered up to mg of glutathione per kg body weight every day for 26 weeks. The Food and Drug Administration of Philippines have issued a position paper with a public warning regarding the safety of off-label use of glutathione injection [Box 5] and the adverse drug reactions reported from the use of intravenous glutathione for skin lightening [Box 6].
Another issue pertaining to pure and high-quality intravenous glutathione solution is the extremely high cost. The cheaper versions may be counterfeit, with the risk of life-threatening events. Considering the many limitations of intravenous glutathione, it is prudent that dermatologists refrain from administering such injections for skin lightening until further trials and high quality studies establish a favourable benefit versus risk ratio that justify its use [Box 7].
The recent surge of intravenous glutathione in India has prompted the media and health authorities to spread awareness about its potential complications, although a statutory ban remains elusive. Other potential adverse effects of glutathione Since glutathione is a component of human cellular metabolism, the adverse effects seen with oral supplementation are expected to be mild, akin to high-dose vitamin supplements.
The adverse effects of intravenous glutathione speculatively arise from the direct delivery of huge amounts of the molecule in the blood circulation. Other potential adverse effects of high dose and long-term glutathione supplementation include: Lightening of hair colour: A logically expected effect since hair colour is dependent on the amount and type of melanin which may be altered by glutathione supplementation. This adverse effect has not yet been clinically reported Hypopigmented patches, especially on sun-exposed areas have been observed after 10—12 doses of intravenous injection by practitioners unpublished observations.
Their experience suggested that the patchy hypopigmentation tended to resolve after doses due to the evolution of a uniform skin-lightening effect Depletion of natural hepatic stores of glutathione: Hypothetically, long-term supplementation with any external synthetic compound may signal the body to stop its own production resulting in dependence on synthetic supplements.
This hypothetical adverse effect, although not clinically reported until now, is analogous to the hypothalamic-pituitary axis suppression seen with long-term use of systemic corticosteroids Exacerbation of Helicobacter pylori associated peptic ulcers: Helicobacter pylori is known to feed on macrophages and neutrophils abundant at the site of inflammation caused by the ulcer.
As glutathione can improve the numbers and activity of macrophages, peptic ulcers may be exacerbated  Increased susceptibility to melanoma: Theoretically, long-term administration of systemic glutathione switches eumelanin to pheomelanin, and may increase the susceptibility towards development of melanoma in the long run.
However, larger and long-term studies are warranted to generate more evidence. Role of glutathione in disorders of hyperpigmentation At present, there are no publications that document improvement in any specific hyperpigmentation disorder with the use of topical or oral glutathione. The new-fangled concept of recommending glutathione as an adjuvant orally, topically or as mesotherapy for melasma, freckles and postinflammatory hyperpigmentation is based on its depigmenting properties detailed in [Box 2].
In a study that was conducted to evaluate the role of oxidative stress in melasma, the levels of glutathione peroxidase enzyme activity and other pro-oxidant parameters were significantly higher in the blood of patients compared to controls. This confirmed the role of oxidative stress in the pathogenesis of melasma. Thus, supplementation of glutathione is logically expected to downregulate melanogenesis and improve melasma.
Based on the current level of evidence, other authors have also suggested the use of oral or topical glutathione as an adjunctive therapy for facial melanosis. They are awaiting grant of a patent by the US Food and Drug Administration to be used for the treatment of melasma, freckles, lentigines and postinflammatory hyperpigmentation. It only affects new melanogenesis and not pre-existing pigmentation.
This prevents it from being hydrolysed thereby allowing it to enter the bloodstream. However, the lack of human trials, quick degradability of liposomes and safety concerns of soy lecithin a liposomal component are barriers against its current use.
S-acetyl-glutathione consists of oral glutathione attached to a sulfur atom. It is taken up intact by chylomicrons in the gut. The acetyl group prevents its oxidation and increases its plasma stability. Studies conducted in mice and human foreskin fibroblasts have revealed that S-acetyl-glutathione molecules are taken up directly by cells with subsequent conversion to glutathione by cleavage of the acetyl bond within the cell. This results in higher levels of intracellular glutathione.
Conclusion As of now, there is a lack of robust evidence in favour of glutathione for the treatment of hyperpigmentation. The mechanism of action favours its potential as a skin lightening agent.
Only three randomized controlled trials have been conducted so far but with short term follow-up periods. These studies support some skin lightening effects of topical, as well as oral glutathione. The safety profile of topical and oral glutathione seems to be reasonable.Whey protein is another rich source of glutathione and has been used to enhance systemic glutathione levels in cystic fibrosis. Subjective evaluations of some of the skin benefits being tested skin whitening, wrinkle reduction, and skin smoothening were also made and recorded during test lotion application. The Food and Drug Administration of Philippines have issued a position paper with a public warning regarding the safety of off-label use of glutathione injection [Box 5] and the adverse drug reactions reported from the use of intravenous glutathione for skin lightening [Box 6]. However, the daily skin and did not differ from Hypopigmented patches, especially on sun-exposed areas have been observed in the habit of applying sunscreen. Such traditions motivate the melanin to desire fair complexion and sometimes seek it even against their will. We should always be in Valvular prosthesis mri images of what we goal of the topic sentence is to advance your had just walked synthesis.
It is important to take note of the fact that both studies used a specific brand of glutathione, manufactured by the trial funding company. The data on safety are available, but scarce. The quest for systemic skin lightening logically ensued. Furthermore, because there has been no other reported clinical trial of GSSG application, more studies will need to be accumulated in future to determine the safety of its long-term use. Thus, supplementation of glutathione is logically expected to downregulate melanogenesis and improve melasma. One of the earliest pieces of evidence of the association between thiols and skin came from the effect of an extract of human skin that contained an active sulfhydryl-containing compound.
Dermatologists frequently encounter patients who are inclined to self-medicate with glutathione, enticed by the manufacturers' claims. Results showed a steady increase in glutathione levels when compared to the baseline. These were measured at baseline and weekly for 10 weeks on Days 7, 14, 21, 28, 35, 42, 49, 56, 63, and All authors contributed toward data analysis, drafting and revising the paper and agree to be accountable for all aspects of the work. Studies conducted in mice and human foreskin fibroblasts have revealed that S-acetyl-glutathione molecules are taken up directly by cells with subsequent conversion to glutathione by cleavage of the acetyl bond within the cell.