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One must develop a thorough understanding of Melasma to achieve successful treatment outcomes. It is one of the most frustrating conditions for clinicians to treat and even more confusing patient.

 

It is estimated that nearly 50,000 women worldwide suffer from Melasma. Described as dark patches of pigment that lie in the upper (epidermis) or mid layer (dermis) of the skin; it commonly appears in facial areas, however it can present in any sun exposed area. Melasma is derived from the Greek word “melas” meaning black.  It is a painless and benign skin condition.

In women, Melasma commonly occurs between the ages of 20-50. In the twenties and thirties, many women take oral contraceptives with synthetic estrogen and/or progesterone to prevent ovulation; the resulting hormonal imbalance can trigger Melasma. Normally, Melasma caused by birth control pills presents on the upper lip. In the forties and fifties, as women enter menopause, estrogen production decreases allowing testosterone to become the dominant hormone in the body, which triggers melanin production along with hair growth and sometimes oilier skin.

Melasma often occurs during pregnancy due to the hormonal imbalances experienced during the gestational period.  Latin, Asian, Hispanic and Middle Eastern individuals, have higher incidences of Melasma. While 90% of Melasma patients are women; 10% of patients, nearly 5,000 worldwide, are men.

Many patients with Melasma do not understand what causes the dark patches on their face and have no idea of how to treat it.  Melasma can be very difficult to treat. One of the clinician’s first tasks is to educate the patient as to what triggers are causing stimulation that produces the uneven pigment in their skin. Patient understanding will lead to compliance with the suggested treatment plan and a successful outcome.

It is critical for the clinician to learn all that they can about the condition, and use the appropriate tools to analyze the skin to develop successful treatment plans. The patient must be thoroughly educated to gain compliance with the suggested professional treatment schedule and recommended daily care products.

Understanding the pigment producing process-Melanogenesis

While a patient may not quite grasp the chemical activity occurring within their skin, if the clinician understands the chemical signals and chain reactions that affects the cells, they can achieve successful outcomes. The clinician must understand how to lift existing pigment, while incorporating ingredients that will suppress the chemical chain reaction occurring within the melanocyte cell.  The practitioner must educate the patient on the importance of incorporating a broad-spectrum SPF to assist in preventing a re-occurrence.

Melanogenesis Process

It all begins when inflammation or hormonal imbalance send a signal to the brain.

  • Inflammation or hormonal imbalances occur, causing the brain to send a signal to the pituitary gland.
  • The pituitary gland forms Proopiomelanocortin (POMC), the precursor to the melanocyte stimulating hormone (MSH). POMC goes through a series of enzymatic steps creating thymidine dinucleotide fragments, which trigger the release of MSH.
  • MSH or melanotropin is released and adheres to the receptor cite of the melanocyte cell.
  • MSH triggers the release of an enzyme (tyrosinase) which initiates the conversion of the amino acid tyrosine to L-DOPA.
  • Next, tyrosinase binds with copper and initiates the conversion of L-DOPA to Dopaquinone.
  • Dopaquinone oxidizes forming melanin which groups together into small “packets” called melanosomes. The color of the melanosomes is determined by genetics. (Eumelanin- black to brown, or Pheomelanin- yellow to red brown)
  • The melanosomes are transferred from the melanocyte cells to the keratinocyte cells through the dendrites. 
  • The melanosomes deposit on top of the nucleus of the keratinocyte cell as a protection mechanism, protecting the DNA within the cell. 
  • The end result of melanogenesis is melanin deposit (hyperpigmentation). Steps 3-6 of the melanogenesis process all occur within the melanocyte cell located at the basal layer of the epidermis. Dermal melasma occurs when pigment leaks into the dermis rather than being transported to the keratinocyte cells in the epidermis. Look for ingredients that suppress multiple points of this chemical chain reaction for successful treatment outcomes.

 

Classifications

While melasma can appear on any sun exposed area of the body, it commonly presents on three areas of the face as follows:

·         Centrofacial- the central part of the face

63% of cases

·         Malar- the cheeks and nose

21% of cases    

·         Mandibular- jawline         

16% of cases

Melasma can also present on the neck or arms. One study confirmed the occurrence of Melasma on the forearms of Native Americans being given progesterone.

 

Depth

Before the clinician can successfully treat Melasma, she must examine the patient’s skin with a Woods Lamp to determine how deeply it lies in the skin. Once the determination is made, the appropriate course of treatment can be selected.

Epidermal

Pigment is superficial, present in the uppermost layers of the skin. When viewed under a Woods lamp, the pigment fluoresces or shines back at you and you can easily see the brown spots under the lamp. A series of superficial chemical peels or often 1 medium depth peel successfully lifts the dyschromias.(pigmented lesions)

Dermal

Melanin has leaked into the dermis, the pigment does not fluoresce back when examined with the woods lamp. Pigment occurs due to an abundance of melanophages (melanin digesting cells) in the dermis. A series of medium depth peels reaching the dermis are necessary to lift dermal melasma.

Mixed

The pigment is located both in the epidermis and dermis. Medium depth peels will be required to reach and lift the pigment.

Undetermined

Dark skinned individuals with an excess of melanocyte cells make analysis difficult. Luckily this classification is rarely used.

 

 

 

 

MASI SCORES

Once classification has been determined, the clinician will determine the severity of the Melasma using MASI scores. MASI stands for Melasma Area and Severity Index. This scoring method provides consistency of documentation and is often used in clinical trials. 

 

MASI scores are as follows

1-       Less than 10% coverage of faint hyperpigmentation

2-       10-29% of the area is affected by mild hyperpigmentation

3-       30-49% of the area is affected by moderate hyperpigmentation

4-       50-69% of the area has severe hyperpigmentation

 

Melasma is often very stubborn and difficult to treat, especially if located in the dermis. Medium depth peels are considered very active and can produce inflammation. Inflammation, along with hormonal imbalances are the catalysts for the melanogenesis cycle that results in pigment production. The key to successful outcomes when using a more active treatments is by incorporating anti-inflammatories such as hydrocortisone post treatment. Common recommended use is at least two to four times a day for two to four weeks post peel. Darker Fitzpatrick skin types need to be especially diligent with post treatment compliance. Often times a 1% hydrocortisone cream will be sufficient following medium depth peel, but if the physician determines it necessary, up to 2.5% strength may be prescribed.  Sunscreen must be worn when going outdoors and reapplied every 90 minutes to two hours or as the manufacturer recommends.

Prevention

Prevention is primarily aimed at restoring hormonal balance, along with use of a broad spectrum UV sunscreen and sun avoidance. It is important to note that once the clinician is successful in lifting existing pigmented lesions, protection from UV exposure is critical.  Sun exposure will reactivate the melanocyte (pigment producing) cells causing a re-occurrence of the condition, often times appearing even darker.

Treatment - Lift, Suppress, Calm and Protect

Treatment requires lifting existing pigment, suppressing the stimulation of future pigment, calming the heat and inflammation in the skin and protecting the skin from UV exposure.

Lasers may be used to treat Melasma, but they generally produce only temporary results. Laser therapy is not the primary choice to treat Melasma as studies reveal little to no improvement for most patients. They may actually worsen some types of Melasma and should be used with caution.

Chemical peels are often the preferred treatment choice. The peel exfoliates the skin, lifting existing pigmented lesions. Some practitioners like to include microdermabrasion or dermplaning with their peel, for a more active treatment. The level of peel chosen, (superficial or medium depth) is determined by the type of Melasma (epidermal, dermal or mixed.)

While addressing Melasma, one must suppress inflammation to prevent stimulating the melanogenesis (pigment producing) process. Some practitioners prefer to pretreat with hydroquinone prior to peeling as HQ is a melanogenesis inhibitor. Others prefer to incorporate anti-inflammatory ingredients immediately following their peels. The combination of pretreating with melanogenesis inhibitors and incorporating anti-inflammatories post peel yields excellent results.

Minimizing sun exposure helps to prevent the Melasma from worsening. While outdoors a sunscreen including Zinc Oxide provides both UVA and UVB protection and should be considered mandatory.

Wearing a wide brimmed hat while outdoors is suggested.

Effective ingredients to suppress melanogenesis and calm inflammation

Melanogenesis inhibitors

Anti-Inflammatory

  • Hydroquinone- inhibits tyrosinase activity
  • Kojic acid- decreases melanosomes & plays a part in suppressing tyrosinase activity
  • Azelaic acid-suppresses tyrosinase
  • Alpha-arbutin- suppresses tyrosinase and melanosome formation
  • Phenylethyl Resorcinol- inhibits the conversion of tyrosinase to L-Dopa
  • Licorice Root Extract (Glizzarhiza Glabra) suppresses tyrosinase activity
  • Retinoids-suppress tyrosinase activity and decrease the amount of melanosomes
  • Vitamin C – causes dopaquinone to revert back to  L-Dopa
  • Mulberry root – inhibits the conversion of tyrosinase to L-Dopa
  • Undecylenoyl Phenylalanine suppresses the production of MSH
  • B-White peptide – Oligopeptide 68 suppresses tyrosinase activity
  • Hydrocortisone
  • Aloe Vera extracts contain choline salicylate (a component of aspirin)
  • Panthenol (Pro-Vitamin B-5)
  • Bisabolol – the anti-inflammatory component of chamomile
  • Vitamin C - Tetrahexyldecyl Ascorbate is non –irritating
  • Resveratrol (from red grape skins)
  • Epigallocatechin Gallate (EGCG) found in green tea
  • Cucumber extracts
  • Hamamelis Virginiana (Witch Hazel)
  • Lavendula Hybridia (Lavandin) Oil
  • Oregano Leaf Extract
  • Wild Cherry Extract
  • Salicylic Acid

 

 

 

   

*This list is not intended to be all inclusive.

Treatment while pregnant and lactating

Many women experience the “pregnancy mask” due to their body’s fluctuating hormones in preparation for childbirth. Melasma occurs more frequently in the second and third trimesters. "Many expectant mothers also experience linea nigra or 'line of pregnancy', the dark line of pigment that extends from the belly button to the pubic area. Linea nigra (Latin for black line) occurs during the second trimester as estrogen levels fluctuate. The line often fades or disappears after birth.  Some women may experience Melasma when hormones fluctuate again during lactation.

Any chemical peel and certain topical creams, including those containing retinoids (Vitamin A) or hydroquinone are inappropriate during pregnancy. An expectant mother can treat skin discolorations with gentler pigment suppressing (melanogenesis inhibiting) ingredients including azelaic acid, vitamin c, kojic acid and licorice. It’s always best to get your physicians approval for any topicals used during pregnancy.

Patients may experience Melasma due to contraceptives, during pregnancy, lactation, menopause, or a genetic predisposition to the condition especially in darker Fitzpatrick skin types. They are often hoping for a quick fix. Clinicians must explain that Melasma won’t disappear overnight. The suppression of reoccurring pigment needs to be a lifetime commitment. Assure the patient that compliance with regular treatments, appropriate daily care, and armed with education on its triggers, you can beat Melasma!

Article By: Brenda Linday  www.lindayconsulting.com

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