Melasma is a common acquired condition of increased pigmentation of the face. It is symmetrical in distribution, i.e., it affects both sides of the face equally. It occurs most frequently in female and in individuals with darker skin types. Melasma occurs in people as early as their twenties and it frequently shows up around or after pregnancy in female. Genetic predisposition is a major factor as over 60% of melasma sufferers have a positive family history. Melasma is rarely seen prior to puberty.
There are 3 general patterns of melasma: centrofacial, malar (cheek) and mandibular. While the first two patterns occur more frequently in younger patients, mandibular melasma occurs patients with more advanced photodamage in the older age group
Other than the face, melasma can occur on the arm and chest. Melasma is closely related with ultraviolet (UV) light exposure. Hormone also plays a very important role. We believe that the treatment target in melasma are melanin. However, we also believe melasma is a photoaging disease and we have to address this when we consider treatment of this condition.
The main player in melasma is the pigment (melanin) producing cells called melanocytes. Melasma is caused by hyperactivity of these cells and an overproduction of melanin. There might also be more of these cells around within area of melasma but we also realize that it might not be so in many cases.
We have different theories of why these pigment producing cells become so active. The initiation factor seems to be UV light. The irradiation of light causes a series of reactions in the skin which cause the release of different chemicals (cytokines, growth factor, hormones, and reactive oxidative species ) which in turn activates the melanocytes in producing more melanin. In addition, there is UV –related basement membrane injury (basement membrane separates the epidermis from the dermis), allowing melanin to “sink” deeper into the skin, making it even harder to be removed.
To treat melasma effectively, we need to target all the contributing elements leading to the disease. No matter what we do and who we treat, it is futile to treat melasma if one neglects sun/UV protection. Recently, we also find that visible light can also stimulate the production of melanin in melasma sufferers. It is important to use a sunscreen combined with a sunblock for the visible light spectrum.
It is also important to address the photoaging aspects of melasma such as a loss of dermal structure (solar elastosis), and an increase in water loss because of the loss of collagen and other ground substance in the skin. Photoaging can be treated with antioxidants, topical vitamin A, vitamin C , platelet rich plasma (PRP) and injectables etc.
We have different strategies for the increase in pigmentation. There are different topical depigmentation agents available to us. Chemical peels, light based treatment including intense pulsed light and laser, energy based devices such as radiofrequency and focus ultrasound are all studied in the treatment of melasma. They all have their pros and cons. None of these methods is 100% effective just because melasma is not a one-dimensional disease. Many players are involved.
What do we do in Reviva Skin Laser Clinic? Fist we have to analyze your skin carefully to find out exactly what hyperpigmentation problem you have. We have treated thousands of patients with different pigmentary conditions and we will advise you on the treatment options that should be helpful to improve your skin condition.
Melasma is a challenging disease. Many new technologies have been promoted to “cure” melasma. We have found that a multi-modal approach including topical products, oral agents and medical procedures are needed to increase the success rate of melasma treatment.
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