The heartache of melasma
- Posted on: Mar 15 2014
By Kimberly Moskowitz, MD
Melasma, derived from the Greek word Melas, meaning “black”, appears as symmetrical irregular patches of abnormal tan or brown pigmentation on sun exposed areas of the face such as the cheeks, forehead, upper lip, and chin. This confidence crushing skin condition is nine-times more common in women than men and affects more than 5 million people in the United States alone. There are few things woman enjoy more than being able to roll out of bed in the morning with youthful flawless skin. Irregular pigmentation on the face is one of the earliest signs of aging skin and it often makes people appear older than they are.
Melasma is often associated with Moms-to-be as it is notoriously known as the “mask of pregnancy”. Although the majority of patients with melasma are not pregnant, it tends to creep onto our skin during the reproductive years, and often coincides with the mainstream panic over fine lines, wrinkles, age spots and gravity. Melasma can also develop with oral contraceptive use or hormone replacement therapy. There is a strong genetic predilection for darker skin types such as Mediterranean, Hispanic, and Asian populations but to date, there is no single known cause of melasma.
Aside from genetics, the most important factor in the development of melasma is exposure to the UV rays of the sun. The paradox of living in Florida is that our beautiful Gulf of Mexico provides a subtropical petri dish for many frustrating skin conditions such as sunspots, skin cancer, premature aging, and melasma.
Melanocytes, the pigment producing cells in the skin, are stimulated by the sun’s UV rays to overproduce melanin. Like a callous, this is the skin’s way of protecting or shielding the deeper layers from injury. This protective mechanism can manifest as a suntan, a freckle, an “Age spot” or melasma. Sun exposure, hormones, pregnancy, skin trauma, and some phototoxic drugs, cause our melanocytes to become overactive, resulting in splotchy deposits of excess pigment in the dermis and epidermis.
Daily application of broad-spectrum UVA-UVB protective sunscreen with an SPF of at least 30, containing Zinc Oxide or Titanium Dioxide is essential for long-term success in treating melasma. Without strict avoidance of sunlight, and daily application of sunscreen, potentially successful treatments for melasma are doomed to fail. While Melasma is physically harmless, it is often emotionally damaging and embarrassing. Fewer than 10% of patients will have remission of melasma without treatment.
Hydroquinone aka “bleaching cream” has been used to treat disorders of hyperpigmentation for more than 50 years. Hydroquinone doesn’t really “bleach” your skin instead; it interrupts the abnormal pigment production by melanocytes, making your skin more uniform in color. Alone, Hydroquinone 4% cream clears melasma in 35-40% of patients. Prescription regimens combining glycolic acid, daily use of a broad spectrum sunscreen, and “triple cream” (Hydroquinone 4%, Retinoic Acid 0.05-0.1%, flourinated steroid cream), clears melasma in 85-90% of patients within 3-6 months.
Beware of over the counter preparations and those found in shopping networks, magazine ads, and cosmetic oounters that convincingly promise miracles yet cause you to lose precious time and money. They have little to no benefit in treating melasma. A variety of “natural” ingredients may help slow pigment production such as Azeleic Acid, Kojic Acid, and L-ascorbic acid (Vitamin C); however, none have been shown to approach the effectiveness of the “triple cream”. Melasma is stubborn and even prescription strength creams may take as long as 3-6 months to show improvement, and possibly a lifetime to maintain it. Deeper variants of melasma are invariably frustrating because topical regimens do not penetrate far enough into the dermis to eradicate the pigment.
Any discussion about treating pigmentary skin disorders would be incomplete without a mention of Laser treatments. Fraxel ™ has catapulted laser technology into a resurfacing revolution with the treatment of wrinkles, sagging skin, droopy eyes, sun damage, stretch marks, pre-cancerous lesions and melasma. Rather than leave millions of faces hidden behind a mask, patients are turning to Fraxel skin resurfacing, which shows a 74-100% clearance rate for abnormal pigmentation including melasma. Fraxel sends microscopic thermal wounds through the skin’s surface to break up the abnormal pigment and destroy over-producing melanocytes. Fraxel ™ Restore and Fraxel ™ Dual 1927 lasers have shown the most promise for those requiring immediate gratification; however, results still must be maintained with diligent sun protection and triple therapy to minimize the inflammatory response.
Establishing realistic expectations is paramount to avoiding a lifetime of exasperation treating a disorder that we can control but often cannot cure. If the curse of melasma is casting dark shadows on your face don’t allow it to conceal your beauty forever and never underestimate the tenacity of this masked marauder. You can conquer melasma with Fraxel ™ dual laser treatments and by taking simple daily steps (Sunscreen and triple cream) to unmask the radiant skin that lies beneath.
Dr. Kimberly Moskowitz, MS, MD
Posted in: Fraxel Dual