Once again, the biggest convergence of dermatologists in the world has begun. This year 22,000 doctors and skin care company representatives are gathered (San Diego this time, thank goodness!) to talk about your skin and melasma was on the list of hot topics! As always, this meeting is a great opportunity to find the most current thinking in the science and the art of dermatology. It's a chance to hear opinions and observations not yet published in medical journals. I’m going to share the melasma “treasure” with you from this year’s meeting.
What’s New in Melasma
Melasma is getting a lot of attention in sessions this year. It’s a common facial skin pigment problem with patches of excessively dark skin. We don’t really know how many people struggle with it, but one team of doctors in the Dallas area conducted a survey and found that almost 9 % of women have melasma.
Most people with melasma are women, but men also suffer from it too, especially those with darker skin. The disfiguring facial hyperpigmentation of melasma can be emotionally devastating. It can even cause social isolation.
Melasma is not a trivial cosmetic skin problem.
For women, melasma starts around the time that their first child is born, or around puberty. It lasts until menopause, at which time it usually lessens.
In melasma, the common facial areas of hyperpigmentation are:
- The central forehead.
The sides of the forehead are usually spared unless the entire forehead is involved.
- There may be symmetric hyperpigmentation above the eyebrows, but there is no excess pigment within the boundaries of the eye bones above or below your eye sockets (meaning your eyelids and surrounding soft skin over your eyes).
- The cheeks, especially around and above the cheek bone.
Cheek hyperpigmentation can run down the side of the face but does not pass below the jaw bone.
- It can also show up on the upper lip.
Other important distinguishing features of melasma include that:
- It does not cause hyperpigmentation on the end of the nose.
- The borders of hyperpigmentation are curved and do not form straight lines.
- Melasma does not go down the sides of the neck. Pigment there is usually from Poikiloderma of Civatte, which is a type of sun damage.
There are other causes of facial hyperpigmentation that can look like melasma, and the treatments are different. This means that it’s important to make an accurate diagnosis.
Don't confuse melasma with other causes of excess facial pigment including:
- Sun spots (which are typically irregular, have discrete borders, and are asymmetrically present on facial sites that have had a lot of sun exposure.)
- Lichen planus pigmentosis (this is a rash that is often gray/brown and diagnosis requires a trip to a dermatologist)
- Drug induced hyperpigmentation (again, a trip to the dermatologist is needed to make this diagnosis)
- Post-inflammatory hyperpigmentation from acne or a rash
Melasma hyperpigmentation is different from these other causes.
What causes melasma to happen?
The cause of melasma is complex and not fully understood.
We do know that melanocyte cells (the skin's pigment producing cells) are stimulated by a number of different things including UV light, but the pigment formed with melasma is NOT the same as a tan. It is much more complex.
In melasma, there is a cascade of events that happen from UV exposure AND visible light, such as from indoor lighting. Yes, indoor (visible) light can also play a role in causing melasma! It means you need more than sunscreen on your skin as I will explain below.
The problem of melasma is more than just a problem of excess pigment, it includes what happens to the pigment and the skin around the pigment.
- Light causes melanin to be formed and cells called melanophages to gobble up the melanin and hold it in both the epidermis and dermis.
- In the skin where melasma exists, there is also evidence of sun damage in the dermis (changes in elastic fibers).
- There are also more blood vessels in the skin where melasma pigment exists!
- Immune cells and dermal fibroblasts are also more active and playing some role in causing melasma.
- Melasma is a very complex physiologic process that can even sting and itch.
- Genetics also play a role in whether you are predisposed to melasma.
What role do hormones and birth control pills or pregnancy play in causing melasma?
Hormones are one of the things that make melasma worse. But, it’s not so much a problem with hormone levels as it is with the hormone receptors in the skin. We know that when a woman takes birth control pills, her melasma can worsen. Oddly, you can’t just lower the dose of birth control pills to lower the risk of melasma. Unfortunately, you need to stop using the pills entirely if you want to reduce the risk of getting melasma from birth control pills.
Yes, our understanding of what causes melasma is becoming more precise, but, what about treatments for melasma?
New treatment ideas for melasma:
First and foremost, you have to block light from getting on your facial skin.
You also need to block visible light and that is best done with iron oxide.
You can find iron oxide in tinted sunscreen products, and your goal is to find products that have 3.2% or more iron oxide. Expect to see products start listing the level of iron oxide in the future. I understand from some of the company representatives that this is already in the works! My Sheer Strength Pure Physical Mineral Matte Tinted SPF 50+ Sunscreen contains 4% iron oxide AND is a pure zinc oxide sunscreen. It's my top choice for melasma!
Many mineral makeups have iron oxide in them, too. I've always recommended mineral makeup for the extra light protection it offers. If you wear or dust mineral makeup over your tinted sunscreen, it will help.
Second, to treat melasma you want to inhibit melanin synthesis by adding products with tyrosinase inhibitors to your skin care routine.
Tyrosinase is a skin enzyme that is important for making the pigment called melanin. Tyrosinase inhibitors stop the melanocyte cells from making melanin. The best tyrosinase inhibitor is hydroquinone. All speakers at the meetings agreed that hydroquinone is safe and essential for treatment of melasma.
You can get 2% hydroquinone products in the US without a prescription and visit to the doctor. This is an effective level of hydroquinone for many people. It is available in my Pigment Fading Pads, which also contain botanical tyrosinase inhibitors as well.
Higher hydroquinone concentrations of 4% or more require prescription. Many speakers use 6 and 8% products for tough cases of melasma.
Most dermatologists, including myself, use this great pigment correcting medicine for a limited period of time (3 to 6 months), and then taper a person off of daily use of high concentration products. Our goal is maintenance use, which might be 2% used 2 or 3 times a week in conjunction with the botanical tyrosinase inhibitors I'll mention below. We often pulse the high dose daily concentration again seasonally, either in summer to prevent worsening of melasma, or in winter to get skin perfectly controlled.
A note about hydroquinone: there have been concerns about hydroquinone because adulterated preparations found in other countries have been associated with ochronosis – a form of black pigment deposited in the skin. Session speakers point out that the cause is not the hydroquinone but mercury and resorcinol added in unregulated hydroquinone products.
Other tyrosinase inhibitors include arbutin, kojic acid, azelaic acid. These don’t work as well as hydroquinone but can be helpful for maintenance once melasma is controlled. They are especially helpful when you stop hydroquinone products because there is often a risk of rebound pigmentation if you are not on one of these botanical tyrosinase inhibitors.
Another product called Cysteamine Cream also inhibits tyrosinase. It is available without prescription but smells like rotten eggs. Apparently, a new product is coming out soon that does not have that smell.
Tyrosinase inhibitors are often combined with strong prescription cortisone creams or immune suppressive products like tacrolimus for the treatment of really stubborn melasma. These medicines have side effects and their use on facial skin must be medically supervised. These help suppress the complex mechanism of inflammation driving the complex pathophysiologic mechanism driving melasma.
Penetration enhancing medicines and cosmeceuticals such as retinoids (tretinoin or non-prescription retinol) and AHA's (such as glycolic acid) help to treat melasma by enhancing the penetration of tyrosinase inhibitors into the skin.
These ingredients can really help improve melasma treatment. They can be irritating and it is really important to avoid irritation because that too can heal with hyperpigmentation, especially in darker complexions.
A new and exciting treatment for melasma is tranexamic acid.
This medicine has been tested and is used in Asia. Research papers were not written in English which is why it has flown under the radar here until just recently.
Tranexamic acid is an oral medicine with what appears to be impressive results. Doses studied in Asia are 250 mg taken twice daily. Intermittent use of 3 month treatment duration during seasonal times of greatest risk are being studied. No one knows how safe it is to use this medicine long term, however, and melasma would require long term usage.
Tranexamic acid is a medicine that appears to inhibit many of the driving pathophysiologic mechanisms of melasma. It has been available in the U.S. since the 1960s for treatment of heavy menstrual periods because it slows the breakdown of blood clots (it is an antifibrinolytic). Right now, the best results for melasma are seen when it is used orally.
What is exciting is that it is also being studied as an injection treatment under the patches of melasma and as a pre-treatment on the skin before micro-needling in a solution of 2 to 5%.
What is the best overall skin care routine to treat and lighten melasma hyperpigmentation?
My Ultimate Pigment and Sun Damage Repair Kit combines the best combination of non-prescription treatments for melasma and other really tough skin hyperpigmentation conditions such as Poikiloderma of Civatte.
The Ultimate Pigment and Sun Damage Repair Kit has made an amazing difference in my longstanding Poikiloderma of Civatte skin condition. I've tried so many products that never made much difference. IPL and Microneedling were of no benefit. I'd almost given up after ten years of trying to find relief for this condition while spending a few thousand dollars doing so. The combination of these products has reduced my symptoms by 50% in two months! I've reduced the amount of heavy coverage makeup on the lower face and neck areas. as the discoloration fades. Plus the kit has improved the overall texture and appearance of my entire face. I anticipate even more improvement over the next few months. Very grateful I took the chance on this kit as it has exceeded expectations and is helping me regain confidence in my appearance. Ms. Green Eyes
It's the synergy of this product combination that works the magic! I use skin tyrosinase inhibitors including arbutin, kojic acid and hydroquinone to turn off melanin production.
Retinol and glycolic acid enhance penetration and also have their own mechanisms for turning down pigment production. Green Tea Antioxidants help fight inflammation that's always seen in skin suffering from melasma. They also help skin to tolerate this professional skin care routine built from powerful products.
Sheer Strength Pure Physical SPF 50+ Broad Spectrum Sunscreen blocks UV induced skin pigment formation (I recommend you select the tinted product with iron oxide). Adding a mineral makeup with iron oxide will also help block visible light from hitting the skin.
I've built the kit with the best skin cleansing routine and moisturizer to help products penetrate and skin to tolerate this powerful complete routine to fight hyperpigmentation. My kit includes instructions to help you achieve success!Click here to see my Ultimate Pigment and Sun Damage Repair Kit - the best skin care routine to fight melasma.
Apply a dusting of my Mineral Makeup Powder to add iron oxide to your skin care routine and help block visible light too. Click here to see all my mineral makeup powders including foundation, blush and eye shadow - crafted with minerals from the earth that also help block all rays of light including UV and visible that can darken melasma.
Don't forget to add a dermatologist approved sun hat to your sun protection strategy!
Check back for my insights from the conference. In the meantime, click here to learn more about my Ultimate Pigment and Sun Damage Repair Kit here.