chemical peels

A derm’s guide: Understanding melasma in 2019

Our favourite dermatologist Dr. Lev Naidoo helps us understand what we need to know about melasma hyperpigmentation. She discusses what it is, how to recognise it, the latest research, and how to treat it.

What is Melasma?

Melasma – sometimes called chloasma or the mask of pregnancy – is a common, acquired disorder of increased pigmentation that affects many people worldwide.

How does Melasma appear?

Typical signs of melasma are light to dark brown patches of increased pigmentation distributed evenly on the face, with irregular borders. It is usually found over the cheeks and/or forehead, bridge of nose, chin and jaw areas. One of the telltale signs of this condition is that it almost always becomes worse during summer.

In past medical studies, melasma was defined as either epidermal (superficial), dermal (in the deeper layers of the skin), or mixed (both in the epidermis and the dermis), based on how the melanin pigment was deposited in the skin. More recent studies show that all melasma is mixed.

Melasma appearance

Who gets Melasma?

Melasma affects most people twenties and thirties. It is seen earlier in lighter skin types than in dark skins, and melasma in men is more common as once believed.

What are the risk factors for Melasma?

Whether you will develop melasma or not depends on factors such long-term exposure to ultraviolet (UV) light from the sun and light sources, so people who tan or spend a lot of time outdoors playing sport are more likely to develop it. Female hormone stimulation (see below) affects it too, and then there’s genetic predisposition – did your mother and aunts have it?

Some people also report that melasma develops or worsens after stressful events that have generated anxiety. The reason for this is that stress and depression raise levels of cortisol. This stimulates certain hormones that cause an increase in melanin production.

What causes Melasma?

It’s complicated!

Our understanding of melasma has evolved.  We used to think of it as a “simple” disturbance of melanocytes, the cells that produce melanin pigment. However, recent analysis revealed almost 300 genes are significantly different, when comparing melasma areas to surrounding healthy skin. This affects the pigment-producing melanocytes and also the dermis. It also, unfortunately, makes the treatment of melasma complicated and ongoing – a lifelong commitment.

It’s photoageing

Recent data also backs the theory that melasma is partly a photoageing disorder – UV damage-induced premature skin ageing.

It’s UV damage

Long-term UV exposure also raises the levels of matrix metalloproteinases in the skin, which degrade collagen. Collagen is an important component of the membrane separating the epidermis from the dermis. When this membrane is degraded, melanocytes and melanin are able to enter into the dermis. This deeper deposit of melanin makes treatment more challenging.

Our oil glands play a part

Oil-producing sebaceous cells also contribute to melasma. This may be why we find melasma in the centre of the face, where sebaceous glands are more densely distributed.

Of course, free radicals have to be involved

People with melasma have higher levels of oxidative stress (an imbalance of free radicals and antioxidants), compared to people without melasma. This leads us to think there may be a connection between free radical injury and melasma.

And then we have our hormones, but all is not what it seems…

For a long time, we believed our female hormones played a part in melasma. A recent study of melasma patients in nine countries, however, minimises the impact of female hormones. It showed that the onset of melasma occurrs in only 20% of cases per pregnancy. Almost 10% of melasma start after menopause. The same study also showed that there wasn’t a significant slowing of melasma once the trialists stopped using contraceptive pills.

It seems cortisol hormones may be at least partly responsible.

Recent research shows the importance of the role of cortisol hormones in melasma. As explained above, the hypothalamus controls the release of melanin-stimulating cortisol, which have a direct effect on pigmentation. The hypothalamus’s role in the limbic system that governs our emotions supports the theory that emotions and stress reactions can cause increased pigmentation in certain people.

How do you treat Melasma?

1. Start developing sun protection habits.

Limit time spent outdoors when sun is at its peak.

Try to use protective clothing and sunhats with a wide brim.

Use sunscreen every day. And reapply every two hours if you are spending long periods of time outdoors or in water.

Current studies show that physical blocker sunscreens (e.g., sunscreens with titanium dioxide or zinc oxide), or combination chemical-filter and physical blocker sunscreens are more effective than chemical filter sunscreens alone in protecting against visible light. These increase the sunscreen’s photoprotective capacity which, in turn, increases the success of melasma treatment.

The sunscreen I often recommend for my melasma patients is Bioderma’s Photoderm M, which combines both chemical and physical blockers. It is fragrance-free, doesn’t block pores and is excellently tolerated even by sensitive skin-types. Its very high UVA/UVB protection has titanium dioxide to protect against visible light. It also contains glabridin, which inhibits stimulation of melanin production.

2. Use a pigmentation-correction treatment

I find products with a combination of pigment-inhibiting ingredients offer the most benefit. It is also important that it offers barrier repair to address the photoageing component of melasma. Addition of an antioxidant further strengthens the capacity for correction.

Products I recommend for my melasma patients include:

Esthederm’s Esthe White Brightening Youth Anti-Dark Spots Serum: A combination of licorice root extract inhibits melanin production, neoglucosamine further inhibits melanin synthesis and is a building block for hyaluronic acid, helping with skin repair. The antioxidants vitamin C, E and superoxide dismutase decrease free radicals, regulate melanocyte activity and decreases inflammation in the skin. Apply this product twice daily to areas with increased pigmentation.

Noreva’s Iklen Mélano Expert Anti-Brown Spot Concentrate contains rucinol and Sophora-α, which inhibit melanin synthesis, centaureidine, which inhibits the migration of melanin to the keratinocytes, as well as Vitamin C.

Le Beauty Club comment: Suitable for use while pregnant and breastfeeding.

Bioderma’s new Pigmentbio Night Renewer – this powerhouse product contains a combination of niacinamide (the biologically active form of vitamin B3 which decreases the transfer of melanosomes from melanocytes to keratinocytes and enhances barrier repair), azelaic acid inhibits tyrosinase and decreases inflammation. It also contains other ingredients effective in treating pigmentation – licorice root extract, vitamin C. Vitamin E and vitamin PP strengthen the skin’s barrier. Apply this product in the evening to areas of pigmentation.

3. Additional support

Beyond anti-pigmentation skin care, you can also improve pigmentation problems with chemical peels, microdermabrasion and micro-needling.

NEED TO KNOW!

It is very important to take skin type and sensitivity into account to decrease trauma or inflammation of the skin.  This makes it essential to only consider these options under the care of your treating doctor. Trauma and inflammation can, unfortunately, lead to worsening of pigmentation problems, especially in patients with darker skin types.

So, remember…

Always sun protect, improve skin barrier quality, gradually integrate active ingredients with pigment-lifting properties into your skin care regime. And always be gentle with your skin.

Here’s wishing you happy skin days,

Dr. Lev
XOXO
Dr

 

 

Dr Levashni Naidoo: Treating pigmentation in summer

I have a complicated relationship with summer: I love feeling the warmth of the sun on my skin, but I don’t love the unevenness with which it marks my complexion.

With summer’s seasonal return, I’ve learned that the sun usually kisses and tells. This can be concerning to those affected by pigmentation problems, so let us look at common factors that may worsen your excess pigmentation and follow our tips to help you with this challenging condition.

Why treat pigmentation?

I’ve treated many patients with pigmentary disturbance. I’ve seen their frustration at having to cover up a condition they wish they could rather spend time improving medically. I’ve witnessed the anxiety they face at the idea of going make-up free. I’ve come to understand the difficulties they face in terms of lowered self-esteem and how self-conscious they feel following the onset of unexpected pigmentary alterations.

Pigmentary disturbance remains a challenging condition to treat. There are over 152 genes that regulate pigment production! This has an impact on how individuals respond to topical treatments, and finding the correct treatment is a process.  It is important to understand that there is no quick fix. I do, however, believe that if dermatologists work closely with our patients, we may embark on a pathway to improvement.

The skin complexion we inherit is influenced by

External Factors

Sunny Days

South Africa is amongst the sunniest countries in the world and sun-induced pigmentation ranks first as both cause and aggravator of many pigmentary disturbances. We all understand that ultraviolet UVA and UVB rays cause photoaging (sun-induced ageing) and increased pigment production. But we also realise now that the visible light spectrum and infrared radiation play a significant role in contributing to skin damage and uneven skin tone through generation of reactive oxygen species (free radicals) within the skin.

Sun exposure may lead to a general increase in pigmentation where skin is exposed, as well as a darkening of pre-existing freckles and the appearance of sun spots.

Heat Waves and Close Shaves

Heat itself from any external source or trauma to the skin may stimulate increased activity of melanocytes (pigment-producing cells in the skin.)

Internal Factors

Heavy-handed hormones

Melasma (hormonal hyperpigmentation) is a common form of pigmentary disturbance. It frequently occurs during pregnancy or when a susceptible person starts using a combined oral contraceptive pill. The increase in oestrogen concentration stimulates melanocyte activity, increasing the production of melanin. This increased pigmentation is commonly found on cheekbones, forehead, nose and occasionally around the mouth.

The aftermath of inflammation

During the active phase of many inflammatory skin disorders – such as acne, eczema and lichen planus – inflammation in the skin may activate pigment production pathways. When the skin is healed, there may be an increase in pigmentation, called post-inflammatory hyperpigmentation (PIH).

Popping pills

Certain types of medication may lead to pigmentary disturbance. These include non-steroidal anti-inflammatories used for pain relief, the combined oral contraceptive pill, antihypertensive (blood pressure), antimalarial, antibiotic and anti-epileptic medications. Telltale signs that you may have drug-induced pigmentation include darkening of your nails and mucosa (lining of the mouth, etc.).

Should you treat pigmentation in summer? Yes!

Treatment of pigmentation has two arms:

One: use one or a combination of treatment agents that effectively decrease pigment production and,

Two: prevent further worsening of pigmentation from continued sun exposure.

The most important aspect of treating pigmentation over sun-exposed sites is to ensure that you protect vigilantly from the sun.

  • This includes avoiding peak-intensity sunlight hours between 10 am and 3pm outdoors.
  • When you’re outdoors, wear protective clothing in the form of sun hats, scarves and long sleeves,
  • Always remember to apply a broad-spectrum sunscreen with both UV, visible light and infrared radiation protection, such as Bioderma Photoderm range

 

What treatment should you use?

Here are your A, B, Cs for treatment of excess pigmentation in the summer months:

A

Always use sun-protection. A broad-spectrum sunscreen should be applied daily in appropriate quantities (a R5 coin amount for your face alone). Re-apply every couple of hours if you are spending time outdoors. Remember, no sunscreen lasts the entire day.

Always remove pigmentation-stimulating agents, such as exacerbating drugs. Speak to your doctor about changing medication, if possible.

B

Brightening agents

Dermatologists may use the following in-clinic treatments to reduce pigmentation:

Chemical peels containing alpha-hydroxy acids like glycolic acid. The strength of the peel will depend on what is clinically suitable for your skin type to minimise inflammation, especially in those with darker skin types. Peels should gently encourage exfoliation of the uppermost layer of the skin, lifting epidermal pigmentation and helping active brightening ingredients from skin care products to penetrate the skin.

Dermafrac is a newer treatment combining microdermabrasion, micro-needling, simultaneous deep tissue serum infusion, and light emitting diode (LED) therapy. In addition to stimulating skin rejuvenation, the procedure also helps with uneven skin tone and hyperpigmentation through delivery of select ingredients into the dermal layer to damp down pigment-producing pathways. This procedure is particularly recommended for those with darker skin types. where stimulation of inflammation through more aggressive treatments may actually worsen pre-existing pigmentary disturbances.

Laser therapy should only be carried out under the care of trained medical professionals. The selection of laser is dependent on the cause of the pigmentation, with careful consideration given to the skin type of the patient.

C

Care at home

In cases of chronic hyperpigmentation, a more intense acute phase of therapy is often followed by a tailored, safe long-term management programme. Treatment in the acute phase may include ingredients like hydroquinone that are prescribed for a short period under supervision of your dermatologist.

Due to side-effects with continued hydroquinone use, a switch to a non-hydroquinone- based ingredient or combination of ingredients is advised.

Skin brightening agents work on various different pigment activities:

  • they may block the formation of melanin,
  • inhibit the transfer of melanin from the melanocyte to other skin cells,
  • suppress melanocyte activity
  • limit inflammation and
  • enhance skin cell turnover

Caution!

Systemic skin-lightening agents have become increasingly popular in recent years. Fernbloc has proven safety and efficacy, but we strongly advise against using other agents such as intravenous glutathione because of severe side-effects, which include renal and liver impairment as well as documented life-threatening adverse drug reactions including Steven Johnson Syndrome.

My recommendations for home care treatment of pigmentation and sun protection

  1. Essential: Sunscreen with a broad- spectrum UVA and UVB cover, as well as cover for visible light. I recommend Bioderma’s Photoderm M  if you have been diagnosed with hormonal melasma as it effectively extends cover to this visible spectrum range. Sun protection is especially important if you have had in-clinic treatments and are using active ingredients such as hydroquinone, retinol, AHA, etc.
  1. Noreva Trio White depigmenting range  is a combination of reductol (a phytonutrient that protects keratinocytes), as well as vitamin C and arbutane that limit melanin production
  2. Esthederm’s Esthewhite range: a combination of murine exopolysaccharise that enhances skin cell turnover, glucosamine and glabridine that regulate melanin production, and vitamin C with added anti-oxidant benefit.
  3. Topical retinoid at night: For first-time retinoid (vitamin A) users, I start with Esthederm’s Intense Retinol Serum – a 0.3% retinol preparation combined with papyrus and apricot oils rich in omega 3, 6 and 9, which improve tolerance of the retinoid. As you develop tolerance, and should added strength be required, I upscale treatment to a prescription-grade retinoid.

Find out more about the Esthederm range here.

Here’s wishing you happy summer days,      

Lev

Dermatologist Dr Levashni Naidoo

 

XOXO

 

 

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