Melasma
Melasma, historically known as chloasma, is an acquired and chronic skin pigmentation disorder that appears as symmetrical brown discolouration, most commonly on the face. Whilst melasma can occur in both men and women, women are more commonly affected. Pigmentation often appears darker in summer and commonly lightens in winter months as a result of less UV exposure.
Symptoms
Melasma is characterised by symmetrical pigmentation occurring most commonly on the forehead, cheeks, upper lip and chin. There is also often background skin redness and vessels present either surrounding or beneath the pigmentation.
Causes
The hyperpigmentation seen in patients with melasma, is caused by over production of pigment (melanin) by pigment cells (melanocytes).
If melanin is found in the first layer of the skin (epidermis) only, it is known as epidermal melasma. When melanin is present in the second layer of the skin (dermis) this is known as dermal melasma. Patients may have epidermal, dermal or mixed (epidermal and dermal) melasma. It is important to determine the type of melasma, as this will determine which treatments are most suitable. Dermal melasma is invariably more difficult to treat than epidermal melasma. We use clinical examination, dermoscopy, Wood’s light examination, and specialised clinical imaging to determine the level of pigmentation.
Apart from an obvious pigment component, there is also a vascular component, with patients often having facial redness and vessels present on examination. It is important to identify and treat this underlying inflammatory process in order to achieve optimal pigment reduction and control.
Melasma is an acquired condition, meaning it is not present at birth but instead develops later in life, often between the ages of 20 and 40 years of age. There is often a genetic predisposition and many patients have another family member who also suffers from melasma.
In some patients there is an identifiable trigger for the onset of their melasma. There are several know triggers, including sun and UV exposure, pregnancy, breast feeding, hormone treatments (oral contraceptive pill and hormone replacement therapy), some medications and hypothyroidism. These triggers are also considered perpetuating factors, meaning they continue to drive the hyperpigmentation process.
Melasma is more common in those with skin of colour (e.g. patients of Mediterranean, East and South Asian and Middle Eastern decent).
TREATMENT
Melasma is a lifelong chronic medical condition of hyperpigmentation and as such there is no cure. Treatment therefore needs to be consistent and ongoing. It also requires a combination of treatments, often with medicines that only doctors can prescribe. Whilst each patients’ treatment plan will be different, there are general principles to follow:
1. Avoidance of triggers
Strict daily sun protection including application of a broad spectrum and high SPF sunscreen is absolutely essential.
Consideration of alternative non-hormonal methods of contraception can be beneficial for some women.
Avoiding the use of potential skin irritants, such as aggressive mechanical exfoliants, harsh cleansers and various perfumed cosmetics, that contribute to the vascular component of melasma.
Various commonly utilised dermal treatments (such as microneedling used in isolation and heat generating laser and IPL) can potentially worsen pigmentation in melasma, particular in patients with epidermal only melasma. This is why it is essential to see a doctor prior to having any skin treatments performed.
3. INCREASE SKIN CELL TURNOVER
In patients with epidermal melasma, increasing the speed of skin turn over (with various topical skin ingredients including retinols and retinoids) and/or assisting the removal of the superficial layers of the skin (with specific skin chemical peels) can complement the overall treatment plan.
5. REDUCE INFLAMMATION
Remove and avoid potential skin irritants and treatments.
Together with appropriately prescribed skin care, vascular laser directly treats underlying inflammation which is a significant known perpetuating factor for pigment production.
A prescription medication* used in women’s heath as a treatment for heavy menstrual bleeding and period pain can interestingly also be used (both orally and topically) for the management of melasma. It works by reducing inflammation and melanin production it the skin.
2. REDUCE MELANIN PRODUCTION
Tyrosinase inhibitors are a group of medications that interfere with the pathway involved in melanin production in the skin. There are various prescription and non-prescription tyrosinase inhibitors that we use for our patients with melasma. We often use multiple tyrosinase inhibitors to achieve more effective lightening of pigmentation. It is important that the right combination and concentration of ingredients are used and for the correct duration for your skin type to avoid complications.
4. TARGET AND REMOVE PIGMENT
Laser treatment is not first line treatment for melasma. In the right patient however, correctly used laser treatment may be helpful. We use a dedicated pigment laser that employs picosecond and nanosecond technology to assist with removal of dermal pigmentation. The laser pulses target pigment by generating tiny shock waves (photomechanical) rather than using heat like a traditional laser (which can be potential harmful for patients with melasma). The body then removes the altered melanin via the immune system.
It is important to note that topical treatment is the mainstay of melasma treatment. Laser treatment should only be considered in the right patient, with the correct type of melasma and with the appropriate laser technology and with a long term treatment plan in place. Various laser treatments have the potential to make melasma worse in both the short and longer term.
HOW ARE WE UNIQUE
Melasma is a medical dermatological condition and needs a medical management plan. There is no one approach for melasma and each patient requires different treatment/s. This is why we encourage you to make an appointment for an initial consultation so we can discuss your melasma with you and make a safe and effective plan with you for the short and more importantly for the long term. We have available the full range of treatment options to effectively manage this often distressing condition for the long term.
*As medical doctors and the fact that this is a prescription medication we are not allowed to mention the ingredient by name.
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