Pigmentation is one of those hard to avoid skin concerns, it is triggered by many factors including hormones, sun exposure and genetics. Melasma is certainly one of the more complex and stubborn forms of unwanted pigmented lesions facing many of our clients.
In this blog we will explore the common triggers for Melasma and the spectrum of treatments and preventions which can help to minimise its appearance.
What is Melasma?
Melasma is quite a distinguishable skin pigment. It appears as patchy, often symmetrical brownish or even blueish-grey discolorations. It commonly occurs bilaterally on the cheeks, upper lip, forehead, and chin area.
So, what triggers Melasma…
Unfortunately, there are a number of predispositions which can contribute to an individual’s likelihood of developing or exasperating Melasma.
Within the Epidermis (the outermost layer of our skin) we have cells called Melanocytes. These cells are often referred to as our pigment producing cells because they store and synthesis Melanin (our skin colour or pigment). In response to various triggers these Melanocytes begin to overproduce Melanin and can therefore alter our skin complexion. Melasma is essentially just a natural skin response to some form of trauma which makes the body synthesis excess pigment. These triggers include the following:
- Fitzpatrick Skin Type
Those who easily tan are far more susceptible to Melasma than those who cannot tan. Generally, Fitzpatrick skin types III, IV and V are most predisposed to Melasma. This is due the composition and structures of their Melanocytes, which make them more sensitive to environmental triggers. Melanocytes in these skin types have larger, more concentrated dispersion of Melanocytes with elongated dendrites. These characteristics mean that their Melanocytes are triggered more easily, have a more dramatic response to stimulus, and hold pigment within keratinocytes (skin cells) for far longer. Overall, they are more prone to Melasma and are often more resistant to treatments.
- Sun Exposure
Sun exposure is the number one cause of pigmentation, this is because Ultraviolet Rays have a direct impact on Melanocytes and their production of Melanin (pigment). Excess Melanin production as a result of sun exposure is essential the body’s natural way of protecting itself. Melasma is triggered by the photoprotective function of Melanocytes to shield the deeper cellular components of the skin. People with Melasma will often notice that after prolonged periods of sun exposure their Melasma has darkened. They may also notice a worsening of their Melasma during summer months, and a lightning during winter months. Sun protection using SPF plays a crucial role in preventing and minimising the appearance of Melasma.
Hormones also have a correlation to the production of Melasma. For this reason, women are far more predisposed to Melasma than men. Pregnancy, menopause, and oral contraception have a direct impact on the levels of estrogen and progesterone. When an imbalance in these hormones occurs, our Melanocytes become far more sensitive, active and susceptible to environmental factors such as sun exposure and inflammation. Essentially these Melanocyte stimulating hormones react to environmental triggers and produce excess pigment.
Why are these triggers important?
If we were to dive straight into our treatment plan without identifying and correcting these Melasma triggers our clients are certainly not going to see long term treatment results. Effective causal diagnosis and correction is particularly important for our hormone triggered Melasma clients. These clients will first need to evaluate their hormone imbalances with a healthcare professional. Once they have worked through this, we can ensure that the treatments we are offering on top will be effective and longer lasting. We need to use a ‘from the ground up approach’ where we correct the causes and then move onto the corrections.
Now the fun bit…developing a treatment plan!
As we have identified and addressed the triggers of Melasma we can now move our clients into the treatment and correction stage of their journey. It is important to highlight that the treatment of Melasma is a journey and therefore it is very important to set realistic expectations with our clients from day one.
Depending on where Melasma sits within the skin will determine the types of treatments we offer and how stubborn and long the journey will be. A diagnostic tool such as a skin scanner or woods lamp is crucial in determining whether Melasma is simply sitting within the epidermis, or if it has ventured into the dermis as well. The deeper the Melasma resides the more stubborn and treatment resistant it becomes.
Here is a quick snapshot of the different types of Melasma:
- Epidermal Melasma: located in the uppermost layer of the skin, has clearly distinguishable borders, brown in colour and is typically more responsive to treatments.
- Dermal Melasma: located in the middle dermal layer of the skin, less clearly defined borders, darker bluish tone, very treatment resistant and more stubborn to remove.
- Mixed Melasma (Epidermal and Dermal): present in both levels of the skin and requires a multi-modality approach to remove.
Epidermal Melasma is a little simpler to treat and can be corrected by using a number of topical and clinic modalities. These treatments work to resurface and strip away the damaged layers of keratinocytes so they can be replenished with healthier ones. Dermal pigmentation on the other hand can require the use of laser-based devices. Lasers work to shatter and break up concentrated pigments so the body can naturally work to break down these foreign cells. Mixed Melasma will require a combination of both these approaches.
There are a number of topical ingredients a therapist can prescribe based on their client’s skin and general health. Ingredients such as Hydroquinone, Tretinoin (Retinoids), Azelaic Acid, Kojic Acid, AHAs and SPF are all commonly found in topical Melasma prescriptions. These ingredients work to inhibit the production of Melanin, promote rapid epidermal cell turnover, minimise the contact between keratinocytes and Melanocytes to reduce Melanin transfer and lighten and soften existing pigmentation.
Chemical peels are a popular and effective treatment for the correction of many forms of pigmentation. They work by stripping the damaged epidermal layers of skin and encourage newer, healthier unpigmented skin cells to generate and surface. A very common form of chemical peel specifically for Melasma is Cosmelan. This treatment involves two phases:
Phase 1: Occurs in salon where the therapist applies the highly potent depigmenting mask which remains on the skin from 8-12 hours after leaving the salon.
Phase 2: At home maintenance which enhances and prolongs the benefits of the in-salon treatment.
Laser based treatments are particularly important for the correction of dermal Melasma, which cannot be removed through topical and superficial treatments. A Q-switched Nd:YAG laser device is one of the most effective laser devices for the treatment of Melasma. This is because the laser is absorbed well into Melanin, but the quick nano second pulse duration ensures no thermal impact on surrounding tissue. It is important to note that Melasma is heat sensitive and therefore a short pulse laser is essential. The laser works by producing an ultra-short pulse of energy that passes harmlessly through the epidermis and is selectively absorbed by the abnormal Melasma pigmentation found in the dermis. This causes the chunks of Melasma pigment to shatter into smaller fragments. These fragments are then recognised by the immune system as foreign bodies and are carried out as waste by the lymphatic system.
It is important to identify your clients Melasma triggers, then diagnose the types of Melasma you are dealing with and finally work together with your client to formulate an effective and workable treatment journey for them.