Hyperpigmentation management

• Melasma is a general term describing darkening of the skin
• Chloasma is generally used to describe skin discolorations caused by hormones as a result of pregnancy, birth control pills or estrogen replacement therapy
• Solar lentigenes is the technical term for darkened spots on the skin caused by the sun
• Sun exposure and hormones (estrogen)  are the major causes of hyperpigmentation
• Hyperpigmentation can also be caused by skin damage, such as remnants of blemishes, wounds or rashes. This is especially true for those with darker skin tones.
• Underlying causes such as oral contraceptive pill, hyperthyroidism need to be addressed first
• If treated incorrectly, melasma can actually worsen
• Lightening cream (in combination with AHA and Tretinoin) and vigilant sun protection are the mainstay of treatment
• Other treatment include the use of specific lasers (q switched Ruby 632nM , q switched Nd:Yag 1032nM) and superficial chemical peels
• Melasma is a difficult condition to treat, improvement is seen after 4-6 months of treatment, longer if dermal melasma is present

Treatment modalities that do not work:

1. Deep chemical peels
2. Microdermabrasion

Some common sense steps to help in the treatment of Melasma

1. Stay out of the sun, exercise smart sun sense
2. Vigilance with prescribed topical medications
3. Avoid expensive cosmetic procedures “promising” a quick fix – treatment of this disorder requires lifelong compliance and some treatments may worsen the condition
4. Avoid injuring your skin by sun exposure (sun burn), tanning booth, picking or scratching, unexperienced use of chemical peels etc especially if you are a darker skin type – the skin’s natural response is to produce more pigmentation to protect it

Topical treatments proven to help in Melasma

Hydroquinone

• Is the most effective ingredient for reducing and potentially eliminating melasma and is considered in medical literature as the main topical agent for treating melasma
• Over-the-counter hydroquinone products can contain 0.5% to 2% concentrations of hydroquinone, while 4% (and sometimes even higher) concentrations are available only from a physician
• Melanin is stimulated by a complex process partially controlled by an enzyme called tyrosinase.
• Hydroquinone inhibit this enzyme, which can reduce or block some amount of melanin production.
• When you prevent melanin from being generated, as new skin cells are formed and move to the skin’s surface, they do not contain the excess pigment (melanin), therefore reducing or eliminating these darkened areas.
• It is not a “bleaching agent” as such

Tretinoin (a form of Vitamin A)

• Is not recommended as the only topical option for melasma
• It is best used in combination with other effective topicals, particularly sunscreen and hydroquinone
• Even though tretinoin by itself can be disappointing for skin lightening, this should in no way diminish its role in the impovement of skin’s healthy cell production, collagen production, elasticity, texture, and dermal thickness.

Alpha Hydroxy Acid

• Primarily  lactic acid and glycolic acid, have a molecular size that allows effective penetration into the top layers of skin.
• Like Tretinoin, by  themselves AHAs in concentrations of 4% to 15% are not effective for inhibiting melanin production and won’t lighten melasma
• Their benefit is in helping cell turnover rates and removing unhealthy or abnormal layers of superficial skin cells (exfoliation) where hyperpigmented cells can accumulate.
• However, other research has shown that lactic and glycolic acids can indeed inhibit melanin production separate from their actions as an exfoliant on skin

Azelaic Acid

• In concentration of 20%
• Generally used for acne
• Is as effective as 4% HQ when used in conjunction with good sunscreen in double blinded studies

Well formulated sunscreen and smart sun sense

• Look for broad spectrum ingredients: zinc Oxide (best), titanium dioxide and Avobenzone
• Smart sun sense is the first line of defense for the treatment of melasma as the problem arises in the first place due to sun exposure
• This means avoidance of sun exposure, 365 days a year liberal use of sunscreen
• No other aspect of controlling melasma  is as important as being careful about exposing your skin to the sun

Alternatives to hq

These agents have research showing their efficacy but there are problems ranging from stability, irritation to skin and concentrations in formulation not high enough to be effective, not to mention expensive

• Hydroquinone-beta-D-glucoside
• Is a derivative of HQ and these ingredients are found in “cosmetic formulations”
• These include Mitracarpus scaber extract, Uva ursi (bearberry) extract, Morus bombycis (mulberry), Morus alba (white mulberry), and Broussonetia papyrifera (paper mulberry)
• Pure forms of Arbutin  are considered potent for treatment of melasma
• Arbutin is derived from the leaves of bearberry, cranberry, mulberry or blueberry shrub
• What has not been conclusively established for most of these hydroquinone alternatives is how much is needed in a cosmetic lotion or cream to obtain an effect
• The tiny amount of Arbutin present cosmetic formulations is ineffective

Kojic acid

• Is a by-product in the fermentation process of malting rice for use in the manufacturing of sake, the Japanese rice wine
• There is convincing research—both in vitro (in a test tube) and in vivo (on a live subject)—showing kojic acid to be effective for inhibiting melanin production
• However, it is an extremely unstable ingredient in cosmetic formulations
• Upon exposure to air or sunlight it can turn a strange shade of brown and lose its efficacy.
• Many cosmetic companies use kojic dipalmitate as an alternative because it is far more stable in formulations. However, there is no research showing kojic dipalmitate to be as effective as kojic acid

Vitamin C

• Magnesium ascorbyl phosphate, L-ascorbic acid, ascorbyl glucosamine, and ascorbic acid are various forms of vitamin C
• There are a few studies showing them to have benefit for inhibiting melanin production
• The problem is that the concentrations of these ingredients were high (more than 5%), which is rarely used in cosmetic formulations.

Adjunctive treatment for melasma

1. Laser – a particular type of laser – Q switched Nd:Yag – works by mechanical dissolution of the melanin
2. IPL – can work with an experienced operator. Caution:  can worsen melasma as the heat from IPL can injure the epidermis and stimulate melanin production as the skin’s response to injury – this is particularly true for darker skin types
3. Jessner’s Peel – works by increasing cell turnover  – cells on the surface in the epidermis containing melanin is shed off with the peel
4. Mesotherapy with lightening agents

What is the prognosis for Melasma

• Dermal pigment may take longer to resolve than epidermal pigment because no effective therapy is capable of removing dermal pigment. However, treatment should not be withheld simply because of a preponderance of dermal pigment. The source of the dermal pigment is the epidermis, and, if epidermal hyperpigmentation  can be inhibited for long periods, the dermal pigment will not replenish and will slowly resolve.
• Resistant cases or recurrences occur often and are certain if strict avoidance of sunlight is not rigidly heeded.

Hyperpigmentation management is suitable for treating the following concerns: