Treating Difficult Melasma Cases

Of the conditions most commonly seen by skin health practitioners today, one of the most stubborn and mysterious is melasma. This type of hyperpigmentation presents in dense patches, often in a symmetrical pattern that is usually seen on the cheeks, forehead, upper lip and chin, and occasionally on other sun-exposed areas, such as the arms and chest. Melasma is more common in women with Fitzpatrick skin types IV-VI, although lower Fitzpatrick skin types may still be affected and 10% of cases do occur in men. 

Presentations and Types of Melasma 

There are 3 different melasma presentations: centrofacial is the most common, appearing on the forehead, cheeks, upper lip and chin; malar, involving the cheeks and chin; and the lower cheek or jawline, known as the ramus, is where the mandibular pattern appears. The different types of melasma are epidermal, dermal and mixed, with epidermal being the easiest to treat.

The etiology of melasma is still not fully elucidated, but many different factors have been implicated in this skin condition. Genetic factors can play a role in the formation of melasma within certain ethnicities,  Asian and Hispanic being more prone to the condition. These typically higher Fitzpatrick skin types tend to have melanocytes that are highly reactive, causing more frequent and undesirable hyperpigmentation in the skin. In addition to genetics, hormonal activity seems to be the most suggested reasoning for the occurrence of melasma. Pregnancy, contraceptives, hormone replacement therapy or hormone treatments can all be responsible for hormone fluctuation. Studies suggest that estrogen receptors on melanocytes can stimulate the cell to produce more melanin.1

The Melasma Area and Severity Index

A useful tool in identifying the intensity of the melasma in a patient is the Melasma Area and Severity Index score.2 The ranges are:

• 0 = no abnormal hyperpigmentation

• 1 = less than 10% of area is affected by faint, barely visible hyperpigmentation

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

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

• 4 = 50%-69% of area is affected by severe hyperpigmentation

 Ingredients that Make a Difference

For some patients, cessation of hormone-altering medications and the normal rebalancing of hormones after pregnancy can cause melasma to fade on its own. This is known as transient melasma. For others, unfortunately, their melasma is known as persistent and can stay pronounced indefinitely. There have been many studies suggesting that the use of gentle, topical home care products and professionally applied treatments is the best way to treat melasma. Placing patients on a daily care regimen with products that include a variety of the following ingredients will help suppress the formation of excess melanin through multiple mechanisms of action, delivering faster, more beneficial treatment outcomes:

• Hydroquinone can be either synthetically produced or naturally found in certain foods, such as berries and wheat. This ingredient inhibits copper from binding with tyrosinase and induces melanocyte-specific cytotoxicity. Although it can be a surface irritant for some skin types, using hydroquinone at a lower percentage, such as a 2%, will help avoid any undo irritation or inflammation in the skin.3

• Arbutin, which is naturally found in blueberries, pears, bearberries and wheat, suppresses the activity of tyrosinase and inhibits melanosome maturation.

• Kojic acid, naturally found in soy and mushrooms, chelates copper bound to tyrosinase, and decreases the number of melanosomes and dendrites.

• Retinoids represent the family of vitamin A. They are synthetically produced and suppress the activity of tyrosinase, decrease the quantity of melanosomes and inhibit melanosome transfer into keratinocytes. Not only are retinoids melanogenesis inhibitors, they also boost cell turnover, which helps accelerate the lifting of hyperpigmented cells. Retinoic acid is an effective topical ingredient, but can be too stimulating for some. Retinol is an effective alternative that is much less irritating and converts into retinoic acid within the skin. A stabilized pure retinol at 0.5% can be beneficial, as pure retinol provides faster results than a retinol complex and, when blended with calming and soothing ingredients, induces minimal irritation.

• L-ascorbic acid (vitamin C) can be synthesized or naturally found in citrus fruits. It converts dopaquinone back to L-3,4-dihydroxyphenylalanine (L-DOPA), which prevents melanin from forming. 

• Lactic acid is naturally found in milk and sugars. It suppresses the formation of tyrosinase.

• Azelaic acid can be found in many grains and castor beans. It provides anti-proliferative and cytotoxic effects on melanocytes and inhibits tyrosinase.

• Glycyrrhiza glabra root extract (licorice) suppresses the tyrosinase activity of melanocytes without cytotoxicity.

• Morus bombycis root extract (mulberry) inhibits the conversion of tyrosinase to L-DOPA.

• Rumex extract is found in various herbs and inhibits tyrosinase production without irritation.

• Phenylethyl resorcinol is synthetically produced and inhibits the conversion of tyrosinase to L-DOPA.

• Undecylenoyl phenylalanine is synthetically produced. It prevents the synthesis of the melanocyte stimulating hormone and suppresses the formation of tyrosinase, and melanin and melanosome transfer.

• Phytic acid, naturally found in various grains and seeds, inhibits the activity of tyrosinase while inducing the exfoliation of superficial melanin-filled cells. 

The use of antioxidants, and calming and soothing agents, such as epigallocatechin gallate and resveratrol, can help in the treatment of melasma as they prevent inflammation in the skin and therefore reduce the incidence of excess melanin formation.

A broad-spectrum sunscreen with a minimum SPF of 30 is needed for patients experiencing melasma. The reactivity of skin prone to hyperpigmentation and melasma is exacerbated by UV-induced inflammation. Therefore, choosing an SPF with added melanogenesis inhibitors and antioxidants can provide additional treatment and pigment suppression along with necessary UV protection. All sunscreens must be applied 30 minutes before sun exposure and reapplied every 2 hours, or after swimming or perspiring, for maximum protection.

Along with a gentle daily care regimen, adding professional treatments can provide a more beneficial outcome. Performing a series of gentle, superficial blended chemical peels containing a combination of lower percentage acids that also contain melanogenesis-fighting ingredients is an excellent way to accelerate the treatment of melasma. Low percentage blends of trichloroacetic acid and lactic acid help to gently remove dead surface cells without causing unwanted inflammation in the skin. This creates the perfect canvas for corrective products to penetrate deeper in the skin to treat the unwanted pigmentation. Modified Jessner’s solutions enhanced with melanogenesis inhibitors, such as kojic and citric acids, are also effective options for treating melasma. Cream-based retinoid treatments are effective when addressing melasma as well, since the inflammatory risk is so low. Retinoid formulations containing antioxidants such as glutathione, bilberry extract and grape seed extract; and melanogenesis inhibitors including lactic and kojic acids, rumex occidentalis and arbutin, are excellent options.

Overtreatment of melasma is quite easy and will cause a worsening of the condition. Anything that causes heat or friction in the skin can stimulate an increased deposit of excess melanin at the site of trauma. This has been demonstrated in many studies assessing the use of intense pulsed light, laser, microdermabrasion and high percentage chemical peels to treat melasma. 

Another mechanical treatment that has shown added benefits in melasma treatment is microneedling. Microneedling has grown exponentially in recent years. This treatment provides an effective physical method of enhancing transdermal delivery of topical ingredients for various skin conditions without causing heat on the skin. Microneedling can be performed with a roller, or pen, which is covered with multiple tiny needles. The needles range in length and can penetrate into the skin up to 2 mm. This not only stimulates collagen production, but also facilitates the penetration of corrective products through the epidermis. It creates minor trauma to the skin, creating less risk of complications, and is generally more cost-effective than comparable laser therapy treatments.4 However, this treatment method can still trigger an inflammatory response, leading to a worsening of the pigmentation if too much trauma is induced. Using a shorter needle gauge will limit the depth of penetration and decrease the risk of further pigment formation. 

Although frustrating for both patients and the skin health professionals working to treat it, melasma can be successfully treated. It is important to note that patients prone to hyperpigmentation and melasma will always be susceptible to recurrence. It is wise to have these patients remain on a continuous regimen containing melanogenesis-suppressing ingredients. A combination of year-round daily care with several pigment-inhibiting ingredients, consistent broad-spectrum sun protection and regular, professionally applied, gentle chemical peels can provide immense improvement of this stubborn condition.

Dr. Linder, board-certified dermatologist and fellowship-trained Mohs skin cancer surgeon, is a volunteer clinical instructor in the Department of Dermatology at the University of California, San Francisco. Dr. Linder is in private practice in Scottsdale, AZ.

Disclosures: Dr. Linder, chief scientific officer, PCA SKIN, is national instructor, Dermik Aesthetics (Sculptra), and national instructor, Allergan Facial Aesthetics.  

References

1. Bandyopadhyay D. Topical treatment of melasma. Indian J Dermatol. 2009;54(4):303-309.

2. Bhor U, Pande S. Scoring systems in dermatology. Indian J Dermatol Venereol Leprol. 2006;72(4): 315-321.

3. Linder J. Treatment strategies for challenging melasma cases. Skin & Aging. 2009;17(2):38-41.

4. Drug-Aware Ltd. Derma Roller. http://www.derma-rollers.com/.