Pigmentation - Melasma Treatment

Most clinics will only offer creams and lotions (and perhaps oral tablets) and not even have device-led solutions.

Even if device options are offered, the below MUST all be avoided:

• IPL Intense Pulsed Light (wavelengths are not specific for pigmentation)
• Ablative Lasers (CO2 and Erbium) – These can result in temporary clearance of pigmentation but will inevitably cause hyperpigmentation and aggravation in the ensuing 6 weeks. These lasers may still be performed for other reasons but not for melasma specifically. If you are having one of these procedures then you will probably need a follow up Picsure Pro 755nm laser treatment to settle any ensuing hyperpigmentation or temporary aggravation of melasma.
• Microneedling – no benefit for any kind for pigmentation
• RF Microneedling – no pigmentation reduction and higher likelihood of aggravation
• Plasma Pen – this works only at the surface level and causes diffuse inflammation that will cause post inflammatory hyperpigmentation.

This condition is often described as mask like pigmentation due to the areas of the face that are symmetrically affected.

Melasma is a symmetrical facial hyperpigmentation that predominantly affects women of darker skin types, although men can also suffer with melasma (the ratio of female to male sufferers is 9:1)

It is estimated that anywhere up to 30% of certain ethnicities can have underlying melasma so it is a It is a very common skin condition.

Excessive melanin production is the problem in melasma causing uneven facial pigmentation of a cosmetically unsatisfactory nature.

Melanin producing cells within the skin produce excess melanin when stimulated by external factors such as sun exposure (UVA) or internal factors such as hormonal changes (pregnancy, contraceptives, hormone replacement therapies).

There is an underlying genetic predisposition to melasma as well but it is not clearly understood.

The excess melanin production is rather like excess oil production in the T-zone. In melasma there is symmetrical excess melanin production on the facial skin and typical areas affected are the forehead, under and around the eyes and the upper lip. This is visible as darker brown patches.

Upper lip pigmentation can be especially annoying as the brown symmetrical patches above the lip can look like a moustache shadow.

The issue is hard to treat as the problem lies in controlling excess production of melanin. This is very difficult to achieve permanently as it would involve rewriting the genetic code of the cells that produce excess melanin which of course is impossible. As such there is no permanent cure for melasma.

This condition is also very hard to treat with oral medications as these would reduce melanin production in all melanin producing cells and there is no way to purely target/focus only on the overactive cells. Therefore there are few recognised medications that can be administered by mouth or intravenously. Tranexamic acid is one that has been shown to help but can often cause irregular periods in women and increase the risk of dangerous clots in the leg (DVT). Glutathione has also been used as an oral medication but it has not shown to be of significant benefit.

Topical creams applied to the skin are a mainstay treatment for melasma. The common feature of these creams is that they contain active ingredients that will suppress the melanin production in the overactive cells. The advantage is that they can be tactically applied to the affected sites on the face to help even out the pigmentation.

The main problem with creams is that they have to be applied continuously and they are extremely slow to improve things. It can take several weeks, sometimes months to see any positive effects. The reason for this is that the actual active ingredient in the cream cannot penetrate the outer layer of the skin effectively. As the problem cells lie deep within the epidermis or even deeper within the dermis only a fraction of the active ingredient will arrive at its target. This problem can be overcome by increasing the concentration of the cream applied but doing this can often cause other side effects such as redness irritation and swelling (irritant dermatitis).

Well known topical treatments are extremely slow to act in the commonly available preparation strengths (typically 4%). It can be specially formulated by a Doctor’s request at higher concentrations but long term side effects of high concentration can cause a condition known as ochranosis. This is formation of a black pigmentation within the skin.

A topical cream containing vitamin A is used, but it does cause irritation. Overuse can cause an irritant dermatitis that can worsen pigmentation. Other topical preparations that are effective in reducing melasma are kojic acid, azelaic acid and niacinamide. Penetration of all these substances to adequate depth is the main problem in topical therapy of melasma. As such all creams for melasma are painstakingly slow to reduce excessive pigment and must be applied regularly to maintain any effect.

Melasma is regarded as a cosmetic issue and as such will not be treated by dermatologists or GPs under the NHS.

As a result melasma sufferers often seek help via medical skin clinics run by doctor or nurses specialising in treatments for the skin. Many non-medical organisations may propose solutions but it is important that the diagnosis of melasma is made correctly and other potential serious skin conditions are excluded.

The mainstay for most clinics is a combination of topical treatments (creams) containing actives. Pharmaceutically produced preparations of these drugs also contain a mild amount of topical steroid to help buffer the irritation they cause to the skin as they have to be applied regularly.

Clinics will often substitute this mainstay therapy with creams containing other active ingredients that are non-prescription such as azelaic acid or kojic acid.

Broad spectrum sunscreen will also be recommended in order to prevent aggravation. In general all of the above are medically acceptable methods for the treatment of excess pigmentation caused by melasma.

Some clinics will use assisted delivery systems for topical medications. When used in the correct way (i.e. with appropriate devices and preparations) this is known as assisted drug delivery. The aim of assisted drug delivery is to use devices to accelerate the penetration of the active substances to the target cells in the deeper layers.

Unfortunately all topical creams are painstakingly slow and require routine monitoring and follow up to help prevent side effects such as dermatitis or problems caused by overuse.

This approach is also costly and to be of any significant benefit the must be used on a regular basis. Compliance with topical regimes requires discipline and just a day or two of forgetfulness and sun exposure can reverse many months of hard earned wins. In short creams are costly, slow and frustrating.

Even when assisted drug delivery mechanisms are used such as microneedling or mesotherapy the result of drilling through the epidermal barrier in itself can cause enough inflammatory trauma to aggravate melasma instead of improve it. In short assisted drug delivery is a relatively new part of skin science and is not fully understood. Uses of drug assisted delivery devices is highly experimental and safety cannot be easily guaranteed. Interference with the epidermal barrier can also lead to significant irritation, inflammation, life threatening anaphylaxis and scarring that will require medical attention.

Caution should be exercised when choosing the provider. Special consideration should be given to whether or not the provider can deal with medical problems such as contact irritant/allergic dermatitis and severe reactions such as anaphylaxis.

Our primary approach to melasma is different. As we all are aware Melasma cannot be cured. We can however reduce the excess pigmentation. Dr H Consult is an international expert in the applied laser approach and an expert in treating darker skin types also. We use the 755nm Cynosure Picosure Pro picosecond laser to treat melasma.

The second laser which used by Dr H for Melasma effectively is the Sciton HALO. This not only will reduce melasma but help with sun damage, superficial pigmentation, texture and fine limes. This is because it is a fractional non ablative resurfacing laser. The advantage versus the Cynosure Picosure Pro 755nm is that more things can be dealt with in a single treatment. The disadvantage is that a longer downtime of around seven days is required for recovery.

In short Picosure is very good for patients requiring short downtime (three to four days flaking and mild redness) with a quick treatment (30 minutes in and out). The Sciton HALO laser is a more comprehensive treatment that will give good melasma and pigmentation reduction, but this approach will require greater downtime (seven days recovery). Go for Sciton HALO if you want the additional benefits and have a little more recovery time.

Our approach is technology-led and laser based, using two cutting edge devices – the Cynosure Picosure Pro and the Sciton HALO non ablative Fractional laser.

The Laser approach works in a very specific way, specifically targeting the melanosomes. Lasers can penetrate much deeper within the skin than creams so the penetration issue is now easily overcome. The other key advantage is that with the particular laser we use (Cynosure Picosure Pro) the pigment is specifically targeted. These are the melanin containing pigment particles within the skin. The Cynosure Picosure Pro 755nm laser specifically targets these without causing trauma to surrounding structures such as blood vessels.

The advantage of the 755nm wavelength it is a longer wavelength that can penetrate deep enough to take out superficial melasma pigmentation located in the epidermis and the deeper melasma pigmentation located deeper in the dermis. So superficial and deep melasma (as referred to by dermatologists) can be both effectively treated.

As mentioned, creams will at best slowly reduce pigmentation in superficial melasma only over a number of months. The Cynosure Picosure Pro 755nm laser can reduce superficial and deep melasma within four days and usually clear the vast majority of it within two to three sessions.

It important to note that the Cynosure Picosure Pro is in fact the only FDA approved laser for melasma treatment.

It is also important to remember that melasma will always creep back. However the advantage here is that we can achieve quick reduction here with minimal downtime (redness and flaking for three to four days) and it is a predictable and effective way of achieving a significant reduction.

As the 755nm wavelength is so specific for melanin pigmentation the benefit here is that it can be used on all skin types safely. Safety also depends on the experience of the user. Dr H is the UK’s most experienced laser skin surgeon and has worldwide recognised expertise in treating darker skin types. on insufficient knowledge and experience in laser dermatology.

The other key lasers for melasma are the best in class Fractional Non Ablative Lasers such the Sciton HALO or Fraxel Dual. The advantage of using these over the picosecond laser is that a number of other issues can be dealt with at the same time.

As these are non ablative resurfacing lasers the skin surface texture can also be improved along with fine lines and wrinkles, sundamage whilst targeting any superficial pigmentation.

With Fractional Non Ablative Lasers the mechanism of action is a little less specific than the Cynosure Picosure Pro. The HALO laser non ablative wavelength (1470nm) creates columns of coagulative damage within the skin called MENDs (Micro Epithelial Necrotic Debris). These columns of damage extend from the surface of the skin into the dermis. This allows for superficial and deep melasma to be effectively treated. As the skin heals the collagen in these damaged areas is remodelled and increases in quantity and quality. Melasma pigment is also destroyed and shuttled out of the skin in a process called shuttling of necrotic debris.

Both Picosecond 755nm (Cynosure Picosure Pro 755nm) and the Non ablative Fractional Lasers (Sciton HALO and Fraxel) are well established laser methods for treating melasma. These laser modalities are comprehensively written about in validated medical literature. Histological (microscopic examination of skin samples) studies have been published showing efficacy on a cellular level which shows much clearer evidence vs simple before and after images.

Dr H Consult is a centre of excellence for Laser Dermatology and as such we only use techniques that are validated by strong medical evidence.

Prior to the development of picosecond lasers (the latest technological leap, only for use in a handful of specialist laser-focused clinics across the world) nanosecond Q-switch lasers were often used to treat conditions such as melasma. Traditionally there has only been Q-switch nano second lasers (at 532nm and 1064nm wavelengths). These can be used when set to the 1064nm wavelength.

However nanosecond laser pulses are not really efficient for the treatment of melanosomes (the pigment containing particles that contain the excess melanin in melasma). The target size of the melanosome particle and the melanin pigment housed within them is too small for effective destruction by nanosecond laser.

With nanosecond lasers thermal confinement is not limited to the melanin containing melanosome. As a result cellular destruction of the entire melanosome containing cells can occur. Treating with a 532nm q-switch nanosecond laser can as a result in prolonged hypopigmentation (loss of pigment). The cellular destruction and excess damage leads to inflammation and post inflammatory hyperpigmentation. Q-switch 532nm cannot be effectively used effectively in darker skin types as a result. The inflammation and post inflammatory hyperpigmentation will also cause a rebound worsening of the melasma when the pigment containing cells reform.

Q-switch 1064nm laser is safer in darker skin types. However this is only because the 1064nm wavelength is poorly absorbed by melanin. This fact means that our objective to reduce melanin in melasma is defeated from the outset. At higher fluences some measurable reduction of melanin may occur but there is also a significant risk of permanent loss of pigmentation (macular hypopigmentation) which will create permanent white spots on the skin. This is due to the permanent destruction of deeper melanin producing cells that would otherwise restore pigmentation.

Lasers and Devices that are not of any specific benefit in melasma should be strictly avoided. These devices cause non-specific reduction of pigment and the inflammatory process that ensues is more likely to trigger rebound melasma and post inflammatory hyperpigmentation.