Are you prone to darkening of your facial skin with sun exposure? We all get a tan during the summer months, this is the normal darkening of our skin as our skin cells produce more melanin, which is a pigment that protects our skin cells from ultraviolet damage from sun exposure. Over time, this melanin rises to the surface of our skin and is naturally exfoliated away as skin cells mature and slough off. This is how our tan fades. But sometimes these cells that produce melanin, melanocytes, become damaged or overstimulated by hormonal imbalances, in men and women, and these menalocytes keep producing melanin, not in a way that produces a nice even tan, but in a splotchy pattern that persists long past summer. This abnormal melanin production is known as melasma. It can occur when exposed to hormones like pregnancy, birth control pills, or can occur during hormonal changes during menopause. It can also be related to a genetic variation known as MTHFR which can cause melasma in men as well as women.
There are prescription medications that inhibit this abnormal production of melanin. The best known of these topical medications is hydroquinone. Hydroquinone is also available over the counter but in lower percentages. Prescription hydroquinone is 4% or higher and is available only through a physician or compounded with a physician's order. Hydroquinone works by blocking the enzyme, tyrosinase, that leads to the formation of melanin. Other topical medications can also block the formation of abnormal pigment such as ascorbic acid (vitamin C). Two additional topical prescription medications that are currently the most promising additions to melasma treatment are cysteamine (brand Cyspera), a very potent anti-oxidant, and tranexamic acid, which specifically targets hormone-induced hyperpigmentation or melasma.
Of course, abnormal pigment on the face is aggravated by sun exposure, not only natural sunlight but also visible light and even light from our computers and smartphones. So it is important to block the sun's ultraviolet light with zinc oxide and titanium oxide and to block blue light from devices. Both ZO and Colorscience sunscreens have ingredients that block blue light from devices, which most sunscreens do not. So now, yes, wear your sunscreen before you go to bed if you are going to be on your smartphone!
Though visible light can aggravate melasma, it is a specific wavelength of light that can also lift and eliminate abnormal deposits of skin pigment, the color cyan. And this is the color that we will use with our Sciton Broad Band Light treatment, also known as Intense Pulsed Light (IPL) or photofacial.
October is a perfect time of year to have an IPL treatment, to lift and eliminate sun spots, freckles and melasma caused by summer sun exposure. An IPL treatment is simple and quick. We will apply a cooling gel to your skin, and then a series of bright flashes of light similar to a camera flash will be applied to your skin. This will feel like brief pulses of heat. Upon completion of the treatment, you will feel as if you have a sunburn, which will last a few hours. You will notice the unwanted pigment begin to darken and over the next few days to week, the unwanted pigment will begin to work it's way to the surface of your skin and naturally exfoliate. For most people, only one treatment is needed, and results last as long as your skin remains protected. Melasma however is very stubborn, as the hormonal imbalances and genetic factors are ongoing. For melasma it will be very important to add topical prescription agents to limit the return of the abnormally produced pigment. I will recommend hydroquinone, zinc and titanium oxide, ascorbic acid, Cyspera, and topical tranexamic acid which is compounded.
We want you to have the best results possible with your IPL treatment and maintain those results for as long as possible. Our skin brightening protocol works for all skin types and colors. IPL treatments can be performed on light to medium skin tones but cannot be performed on the darkest skin colors as it may lead to a burn.
My recommended skin lightening and brightening protocol are:
Salicylic 2% exfoliating and calming pads
Hydroquinone 4% with Ascorbic Acid (Vitamin C) to prevent the formation of unwanted pigment
Tretinoin (Retin-A) to speed up the removal of unwanted pigment
ZO Daily Power Defense to normalize moisture production
Glycolic Acid 10% to exfoliate dead dry skin cells and speed up the removal of pigment
Topical tranexamic acid, compounded, for Melasma
Topical Cyspera - currently the only practice in DE to offer this product
Zinc and titanium oxide with blue light protection Sunscreen
Physicians see it regularly—symmetrical patches of excess pigmentation across the nose and/or on the cheeks, chin, and forehead. Sometimes called the “mask of pregnancy,” melasma is more common among women but is also seen in men. Causes include a complex combination of genetic and hormonal influences that are not yet fully understood, and treatment is challenging.
Melasma can be categorized according to location patterns and depth of pigment in the skin. The three typical patterns are centrofacial, involving the cheeks, forehead, upper lip, nose, and chin; malar, involving the cheeks and nose; and mandibular, involving the lower sides of the face.
While physicians currently employ a wide array of treatments ranging from sunscreens and daily topical lighteners to controlled skin peels and laser or light-based procedures, reliable, consistent, long-term clearance of melasma remains among their most difficult challenges.
Epidermal vs. Dermal
The depth of the melasma pigment can be epidermal (more superficial) or dermal (deeper); however, the majority of cases involve pigment in both skin layers. Determining the depth of pigment deposits can be difficult.
Determining the type of melasma and depth of excess melanin deposits is important in providing the most effective treatments and advising a patient on the most likely prognosis. In the epidermal form, characterized by brown color, melanin is found in the basal and suprabasal layers. In dermal melasma, which appears more blue-gray, melanin is found in the superficial and deep perivascular melanosomes. The epidermal form is easier to treat and more amenable to topical therapy, while dermal or mixed melasma is more resistant to treatment. Dr. Parsons is able to treat both superficial and deep melasma with our Sciton BBL Intense Pulsed Light device.
First-line treatments involve sun protection and some combination of topical skin lighteners and chemical or mechanical peels. Experts recommend a broad-spectrum sunscreen that protects from both UVA and UVB rays and is water-resistant with an SPF of at least 30. It is important that the sunscreen has zinc oxide and/or titanium oxide, to block the UVA and UVB rays. Experts also recommend sunscreens that block blue light. Only a select few sunscreens block blue light. Wide-brimmed hats and other protective clothing are recommended during extended periods in the sun.
“I recommend tinted sunscreens containing iron oxide such as ZO Skin Health Triple Protection Sunscreen + Primer with natural melanin and iron oxide to block visible light, antioxidants, and zinc and titanium oxide SPF 30,” says Dr. Michelle Parsons. “Iron oxide not only provides a tint but also blocks visible light, which worsens melasma.”
Patients should also minimize UV exposure while in a car. “Patients may not think they spend a lot of time outside, but even incidental UV exposure—through car windows, home windows, for example—can worsen melasma. UVA rays, in particular, contribute to skin darkening through windows,” says Eric F. Bernstein, MD, of the Main Line Center for Laser Surgery in Ardmore, Pennsylvania. “Having photoprotective film professionally applied to car windows to block UVA rays can be a big help.”
Clear window films such as Llumar and Solar Gard block 99% of UVA and don’t hinder night vision. Car windshields already contain a layer of clear plastic mandated to help prevent broken glass from flying through the air after an impact, but it is not designed to block UVA.
In addition to photoprotection, Dr. Parsons recommends topical therapy. “Effective melasma treatment includes removal of the excess melanin in the epidermis and dermis as well as suppression of further melanogenesis. Without these two steps, there is a high risk for relapse,” she says. “The gold standard for first-line melasma treatment is strict photoprotection and topical therapy, using either hydroquinone 4% cream, tretinoin or triple combination creams.”
Triple combination creams, such as Tri-Luma (Galderma), which is FDA-approved for treating melasma, include a combination of hydroquinone, tretinoin, and a topical steroid.
“Our first-line treatments include 4% hydroquinone, as well as azelaic acid and kojic acid in combination with tretinoin, and broad-spectrum sunscreen. For very stubborn melasma I will add topical Cyspera a very potent anti-oxidant, and topical tranexamic acid, especially for hormonally related melasma” says Dr. Parsons. “Patient satisfaction depends on the severity of the condition, but a high percentage of newly diagnosed epidermal melasma patients get satisfactory results. Patients with dermal melasma will need a lot more patience.”
Pregnant patients should first consult their obstetricians regarding which products they can safely use. “We cannot utilize tretinoin, hydroquinone, Cyspera, or tranexamic acid during pregnancy. Most pregnant women with melasma can use AHAs versus retinoids during pregnancy and chemical-free, non-nanoparticle physical sun blockers,” says Dr. Parsons.
For many patients, first-line treatments are not satisfactory, but experts don’t always agree as to the best, most effective option for persistent cases.
“For persistent melasma, we continue first-line topical treatments and add physical therapies, such as peels and microneedling which does not cause chemical injury to the epidermis, thereby increasing clearance rates and reducing the risk of hyperpigmentation,” says Dr. Parsons. “When all other modalities have failed, I will recommend intense pulsed light (IPL) treatments, depending on the chronicity of the condition, previous treatments, and skin type. Current evidence from randomized studies suggests that low-fluence QS Nd:YAG and IPL provide the most effective results. Fraxel CO2 lasers have been shown to be not effective for treating melasma.”
“I will also treat selected patients with oral pills such as tranexamic acid after I take a thorough medical history. Oral pills are not for everyone. They should not be given to certain patients, including those with clotting problems, and can cause side effects.”
IPL shows better results in primarily epidermal melasma and with Fitzpatrick skin types 1 to 3, while the QS Nd:YAG has broader efficacy in treating both dermal and epidermal melasma, “When these devices are combined with effective photoprotection and topical lightening creams, the improvement in melasma is significantly better, and risk of relapse lower than when using any of the devices or topical therapies as monotherapy. After laser therapy, it is important to counsel patients to continue using photoprotection and a topical lightening agent to reduce recurrence risk.”
But whichever light or laser source is employed, results require multiple treatments, and hyperpigmentation is likely to recur.
If you would like to begin the recovery process from a season or years of sun exposure and remove areas of unwanted skin pigment and damage or if you suffer from melasma, please call us to set up your IPL treatment and begin having lighter brighter skin and even complexion now.