I Hate Melasma

Finally, the last installment in the Out Damn Spot, Out, Out, I Say series on brown spots on the face, what they are and how to get rid of them. We have discussed brown spots from sun damage, raised brown age or liver spots, brown spots after acne, cosmetic skin procedures or injury. So now, Lady Macbeth, we go on to the bane of the cosmetic dermatologist’s existence, melasma.

How to Get Rid of MelasmaHow to get rid of melasma

Finally, the last installment in the Out Damn Spot, Out, Out, I Say series on brown spots on the face, what they are and how to get rid of them. We have discussed brown spots from sun damage, raised brown age or liver spots, brown spots after acne, cosmetic skin procedures or injury. So now, Lady Macbeth, we go on to the bane of the cosmetic dermatologist’s existence, melasma.

I hate melasma. I really hate melasma. What is that you say? “That is a bit harsh Dr. Elaine, hating on a skin disease.” True. But here is why I hate melasma: I have had it. I treat it. It is really difficult to treat. It is really difficult to treat because the factors that cause it are very hard to modify. The factors are hard to modify because they are factors that are part of life: sun exposure, hormones, and skin type. Add to that the fact that the medications that we use are really hard to get right now. Often the treatments we use to treat it cause inflammation, and inflammation worsens melasma. The women who get it often have more natural pigment, which makes them more likely to pigment with treatments for melasma. Melasma is very persistent and sneaky, it often responds to treatment, but waits patiently for a tiny sliver of opportunity to start up again. Then it does, and both patients and cosmetic dermatologists get frustrated. And that is why I hate melasma.

To recap, here is what you see with melasma:

  • In the mirror: Large dark flat patches of discoloration, usually symmetrical, over cheeks, jawline, fore head and above the upper lip. It is often more obvious in low light settings, such as at sunset. It responds almost instantly to any sun exposure. It is hard to cover up with makeup.
  • Diagnosis: Melasma or “mask of pregnancy,” is caused by a combination of hormones, predominantly estrogen from pregnancy or birth control pills, and sun exposure. Once it starts, melasma tends to reoccur very easily with minimal amounts of sun exposure, even if the hormonal trigger is removed. I divide melasma into two types: “relatively easy” and “hard.” The difference is dependent on how deep in the skin the pigmentation is found, and whether both the hormonal stimulation and sun exposure can be reduced. Deeper pigment is always harder to improve.
  • Treatment: Involves both removing the triggers, and using creams and procedures to reduce existing pigment. Daily, year round, broad spectrum sun protection and avoidance of sun exposure is absolutely essential. Reducing hormonal triggers is often a challenge as pregnancy eventually ends, but often the need for birth control continues. Even if the hormonal trigger is removed, the melasma remains “turned on” and even tiny amounts of sunlight cause it to reoccur. Treatment at home with skin lighteners, prescription skin bleaches, retinoid creams, and sunscreen, combined with in-office chemical peels or SilkPeel microdermabrasion are tried first. “Relatively easy” melasma usually responds fairly well to this treatment. For more resistant cases, Intense Pulsed Light, laser, and deeper chemical peels under the supervision of a dermatologist experienced in treatment of pigment, are considered. Results are varied, and these procedures may actually make pigment worse.
  • Ease of treatment: Difficult-very difficult.

Melasma is almost exclusively a skin disorder in women, though very occasionally it occurs in men. It is caused by a combination of estrogen, and to a lesser extent, progesterone, hormones, found in birth control pills or devices, naturally occurring during pregnancy or just the hormones made by the body, in combination with sun exposure. It shows up as dark patches of brown pigmentation most commonly on the sides of the face, the forehead, above the upper lip, on the chin, and on the sides of the neck. Mild melasma appears as small faint brown splotches, but more severe melasma surfaces as patches of light brown skin pigmentation. There is a genetic susceptibility to melasma, and it is more common in women with skin that pigments easily. It is especially common in women with Asian, Hispanic or African American skin type. There are more active pigment producing cells called melanocytes, and the melanocytes are more easily triggered to produce melanin. The excess melanin is stimulated most significantly by sun exposure, but also by heat, and anything that irritates the skin like facial scrubs, brushes, irritating skin creams, medications or treatments. Once melasma is triggered on, even minimal amounts of sun exposure will cause it to darken or return after successful treatment. It is more apparent during and after periods of sun exposure and less obvious in the winter months.

Melasma can occur at either the surface level (superficial melasma) or in the deeper layers of skin (dermal or deep melasma), giving it more of a spread-out appearance. One way to determine whether your melasma is superficial or deep is to stretch the skin. If you stretch out the brown patch and it appears lighter than when the skin is not stretched, then the hyperpigmentation is superficial. If it’s darker when stretched than it is when not stretched, then the pigmentation is deeper.

I pigment moderately easily, and had a decade or so dealing with melasma. It is often in a pattern, which is why it is also called the “mask of pregnancy” and I had a delightful set of horns above my eyebrows and a brown pigment moustache. Melasma drives women crazy, and is incredibly frustrating. I was no exception. Usually it finally burns out, and mine did.

There are two reasons that melasma is so hard to treat. The first reason melasma is so hard to treat is because even minor amounts of sun exposure can darken or reactivate it. It is hard to avoid all sun exposure, especially in women in the age group most commonly affected, 25-40, who may have children with outdoor activities. The other reason is that estrogen and progesterone hormones go along with being female. And women in that age group are faced with the decision to either be on birth control pills, or be pregnant, both of which are triggers.

There is no single treatment that works for all melasma patients; therefore, we develop an individualized treatment plan for each patient. Combination therapy usually is needed and recommended. Because the melanocytes are easily irritated, and when irritated they produce more pigment, we avoid aggressive treatments that may lead to more pigmentation, white blotches, or scarring. Treatment options range from topical bleaching and prescription medications to techniques such as IPL, chemical peels and microdermabrasion as well as lasers and light sources. We plan a stepwise approach to treatment beginning with home treatment, stepping up to office procedures as needed if results to home treatment are unsuccessful. If office procedures are needed, they should only be performed by cosmetic dermatologists with extensive experience in treating pigment problems.

Because of the difficulty in reducing pigment, the ongoing hormonal issues, and the tendency for melasma to reoccur we discuss in detail the lengthy treatment times and commitment needed to success­fully treat melasma to help manage unrealistic expec­tations. We also discuss the importance of and strong commitment to the sun protection program that is central to treatment. But even in the face of our hormones and our lifestyle, we soldier on and treat it the best we can with realistic expectations for improve­ment. And here is what we do:

Home Treatment:

  • Daily Sun Protection: Is absolutely essential for successful melasma treatment and should start early and continue throughout treatment and also after melasma has improved to help prevent recurrence. Exposure to UV radiation and even visible light activates melanocytes and causes melanin to deposit in the skin. Sun protection with a broad spectrum sunscreen which covers both UVB and UVA with a SPF of 30 or greater used every single day, year round, and reapplied every 2 hours during sun exposure is essential. And that goes for all skin types, even patients with darker skin types who do not routinely use sun protection. But you have to remember that no sunscreen will block out all UV rays, so you cannot put on sunscreen in the morning and go out all day. Patients must limit time in the sun, and wear a hat whenever possible if sun exposure cannot be avoided. As a matter of fact, it is so important, that if you are not willing to modify your sun exposure, stop reading and go play on Facebook.
  • None of the other treatments may be used during pregnancy. If you are pregnant and at risk for melasma, start immediately to protect your skin from sun exposure to prevent melasma. If you are pregnant and have melasma, scrupulous sun exposure will help keep melasma from becoming more established.
  • Prescription Hydroquinone (HQ) skin bleach: Hydroquinone is skin bleach that has been used for years. It inhibits the enzyme tyrosinase which is essential in pigment production. It comes in an over the counter 2% concentration, and stronger and more effective 4% prescription concentration. It is effective for approximately 20 weeks of treatment, then the skin becomes used to it, and effectiveness decreases. If used longer than 4-5 months, rarely an irreversible darkening of pigment occurs, especially in patients with darker skin types. It is usually applied twice daily and should be applied to the entire face because bull’s-eye areas of discolor­ation can develop from localized or spot treatments. Unfortunately it is irritating to the skin and if irritation occurs it can actually cause darkening of pigment. It has been very helpful in the treatment of pigment problems, but has recently come under fire from consumer groups and the FDA because of safety testing concerns. The most effective of the prescription forms, in my opinion, was Tri-Luma cream, which is a combination of HQ, a topical steroid, and tretinoin. It can only be used for 2 months at a time because the topical steroid component can cause dilated blood vessels and thinning of the skin if used longer. Currently it is not being produced, and has been unavailable for the last year. Intermittently other prescription HQ products are available, and then they disappear. HQ at 4% concentration is a prescription product, and recently the FDA has been cracking down on products available without prescription that contain 4% HQ. Time will tell if HQ will be banned by the FDA, approved by the FDA, and if so, will a company produce it. After about three to four months, the body increases tyrosinase production and overrides the effects of HQ. Because of this, HQ is used is a pulsed manner, usually 4 months on, 2 months off, to allow it to work again. HQ cannot be used in pregnancy.
  • Prescription retinoid creams such as Retin-A, Retin-A Micro, Refissa, Renova, Differin, and Tazorac: Topical HQ often is combined with a topical retinoid, such as tretinoin, which exfoliates the skin and allows for the ingredient to penetrate properly. Unfortunately, they can be irritating, and irritation increases pigment. So they need to be used cautiously. Retinoid irritation can be reduced by titrating the dosage, changing the dosage to alternate days, and diluting the tretinoin with a moisturizer base. Creams or micro sponge formulations are much easier to tolerate than gels. The key is to have your face completely dry before you put it on at night, and use it on a regular basis, not intermittently. When your face is damp you absorb more and it is more irritating. You can apply it every other night or even every third night to start and work up. If you are having irritation, apply an oil free moisturizer first then the retinoid.
  • Over the counter Retinol: The prescription retinoids discussed above are forms of retinoic acid, and are stronger than retinol. Non- prescription, over the counter retinol can be helpful in melasma treatment as long as it doesn’t cause irritation.
  • Mequinol such as Solage solution (mequinol 2% and tretinoin 0.01%): If HQ causes the patient too much irritation, a deriva­tive alternative is mequinol.
  • Over the counter or natural skin lighteners: include aloesin, arbutin, azelaic acid, bearberry extract, dimethylmethoxy chroman palmitate (Chromabright), ferulic acid, kojic acid, lactic acid, licorice root, lignin peroxidase, mulberry bark extract, N-acetylglucosamine, niacinamide, soy protein, various peptides, and vitamin C especially magnesium ascorbyl phosphate or L-ascorbic acid. These lighteners have various actions including inhibiting the pigment producing enzyme tyrosinase, dispersing pigment, and exfoliating pigment. They can be used for extended periods of time and can be used with other lightening ingredients to speed up the process.
  • Every dermatologist and skin care company has their favorite combination. Our Antioxidant Skin Lightener contains aloesin, licorice root, bearberry, niacinamide, the form of active vitamin C magnesium ascorbyl phosphate, (Melfade-J) and dimethylmethoxy chroman palmitate (Chromabright). We use it with our Correcting Serums containing glycolic and salicylic acids, fruit acids, aloesin, and our Antioxidant Enzyme Peel containing papaya to exfoliate abnormal pigment.

Office Treatment:

Office treatments are used if topical creams don’t give enough improvement and to speed results. They must be done very carefully or they can cause increased pigmentation, especially in patients with darker skin types. They should be done very carefully, and by a physician who is experienced in treating pigment problems and skin of color, in other words by a cosmetic dermatologist.

  • Chemical Peels: A series of in-office light chemical peels can improve discoloration by peeling off the top layer of pigmented skin cells, and allowing better penetration of other surface treatments. Glycolic acid peels are most commonly used but others include salicylic acid, superficial trichloracetic acid, lactic acid, tretinoin, 14% HQ, and resorcinol peels. They are best when used with home retinoids, prescription hydroquinone or other skin lighteners. Skin may be red, dry and flaky for up to 5 days.
  • Intense Pulsed Light (IPL): A series of 3-5 Intense Pulsed Light treatments (IPL, Photofacial, or Photorejuvenation) at a lower intensity than is used to improve sun damage induced dilated blood vessels and age spots can be helpful.
  • Particle Free Precision Microdermabrasion/Dermal Infusion such as SilkPeel: SilkPeel particle-free microdermabrasion uses a treatment tip to exfoliate the skin accompanied by application of the skin brightening peptide Decapeptide-12 (Lumixyl) at controlled intensity. It removes surface pigment, and allows better penetration of prescribed home skin treatments. A plus is that there is no redness or flaking after treatment.
  • LED Treatments: GentleWaves LED Photomodulation uses a painless light emitting diode treatment and is used to reduce inflammation with other melasma treatments.
  • Nonablative Laser Treatments: The Q switched 1064-nm Nd:YAG laser and the fractional lasers Fraxel Restore and Mosaic may be used in patients who don’t respond well to the treatments above or who also desire improvements in mild to moderate wrinkles, large pores, surface irregularities, or acne scarring.
  • Ablative Lasers: Multiple treatment sessions with the Pearl 2790-nm Er:YSGG laser combined with IPL and topical treatments in carefully controlled protocols may be used in carefully chosen patients with skin types I-IV if melasma does not respond to other measures.

Sometimes things that seem that they should be easy are not. This is one of those times. With diligence and time melasma can be significantly improved or resolved. But I still hate melasma.