Treatment for facial pigmentation forms a bulk of my daily workload as an aesthetic physician. In sunny Singapore, it is an uphill task for many people to keep pigmentation at bay. One of the most common pigmentation conditions I see at work is melasma. Correct, regular use of sunblock is key in any pigmentation treatment plan. When this basic component is settled, there are a plethora of both over-the-counter and medical-grade treatments that are effective in reducing pigmentation. Of course, the first step to treating pigmentation is getting the diagnosis right, as there are many types of pigment conditions. I will be discussing Melasma management in this blog post.
What is Melasma?
Melasma is a common pigmentation condition that appears as brown or greyish patches on the face, often in a symmetrical pattern on areas such as the cheeks, forehead and nose. Women are more prone to it. A common story I hear from my female patients is of the pigmentation appearing, or getting worse after they got pregnant, or had children. Hence, it is often dubbed 'the mask of pregnancy', alluding to the fact that is can be triggered by hormonal changes.
While it is possible to lighten the melasma pigment, there is unfortunately no permanent cure for it. Hence, it has to be continuously and carefully managed to be kept under control (like a spoilt child). Some factors associated with melasma are genetics, sun exposure, certain medications and hormonal changes.
Can home care/over-the-counter remedies work?
Yes they can! I have reiterated countless times to my patients that the most important part of melasma management is proper, regular sunblock application - not lasers, not lightening creams. Proper sunblock application will prevent melasma from worsening and can even help it fade over time. You need SPF 30 minimum and the correct amount would be 2 finger lengths for the entire face. Sunblock is needed when you are indoors too as the windows do not block against harmful UV rays.
Next up, active ingredients that can be found in over-the-counter preparations. I will list some that have been medically proven to be able to lighten pigmentation.
Vitamin C
Arbutin
Kojic acid
Retinol
Azelaic acid
Of course, do exercise caution and avoid mixing too many active ingredients from the get-go to avoid problems such as skin irritation. An example of a simple regime that could work would be inclusion of a vitamin C serum in the daytime, and then a serum or cream that contains retinol at night.
When to see a doctor? What can the doctor do?
If your melasma still bothers you despite your best efforts in taking care of your skin and avoiding the sun, then it might be helpful to get a medical consultation.
First, a diagnosis should be made. Is it really melasma? Or could it be something else which requires a different treatment approach? There are certain pigmentary conditions which may resemble melasma, such as Hori's naevus, Naevus of Ota, lentigo or post-inflammatory hyperpigmentation.
Once the diagnosis of Melasma is confirmed, treatment can be started. A 3-pronged approach can be used to manage melasma.
1. Laser treatments
Laser treatments work by targeting pigment in the skin and shattering them into smaller particles, while not damaging the surrounding skin. These particles are then removed via natural processes in our body. For melasma, the laser treatments have to be gentle and done on a regular basis (e.g 2-4 weekly). When laser settings are too strong or the treatment settings are too close, there is a risk of rebound darkening or abnormal pigmentation, such as unsightly white spots on the skin (guttate hypopigmentation).
There are many lasers on the market which have been shown to be helpful in treating melasma. In my practice, I found regular laser-toning with the Q-switched laser to be a safe and effective way of lightening melasma. In addition, the thermal energy from the laser also stimulates collagen production, making this a good anti-ageing/skin rejuvenation treatment as well.
2. Medical-grade creams
Medical grade creams like hydroquinone are often prescribed alongside laser treatments to improve results. Hydroquinone is a well-known skin lightening agent which has been used for decades. It works by reducing melanocytes in the skin. Melanocytes are cells that make melanin (the pigment).
There are also combination creams for lightening melasma. These may contain a combination of hydroquinone (for skin bleaching), retinoid (to increase skin cell turnover) and mild steroid (to curb underlying inflammation that drives the melasma process).
Another medically-proven topical skin-lightening agent is Cysteamine cream. It works by inhibiting the production of melanin in the skin, scavenging free-radicals and increasing the production of intracellular glutathione, an important anti-oxidant.
In Singapore, these creams have to be prescribed by a doctor, who will also be responsible for monitoring the progress of your treatment and any potential side-effects.
3. Oral medication
There have been various scientific studies on the use of oral tranexamic acid in treating melasma. Most of the subjects studied were Asians with melasma, since it is a condition more common in Asians with more pigmented skin. It works by suppressing melanin production, blocking certain biochemical pathways and enzymes that are required for melanin(pigment) production. It has been found to be a safe and effective treatment for reducing melasma, even in challenging cases that have not responded well to laser treatments and medical-grade creams.
It has to be prescribed by a doctor who will discuss with you your suitability and any potential risks/side effects. It is typically given in low doses for an average of 2-3 months.
In a nutshell
Melasma is a long-term skin condition that waxes and wanes in severity. The basics of preventing and controlling it is straightforward - sun avoidance and sun protection. While it is a harmless condition, it can be bothersome and cause psychological distress to some. Once the diagnosis is confirmed, treatment is fortunately non-invasive with no downtime and fuss-free. I personally find it satisfying to treat melasma so if you have any concerns about your melasma condition and need some advice, feel free to drop me a message.
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