MELASMA TREATMENT IN DELHI
What is Acne?
Melasma is a very common pigmentary disorder in which hyper melanosis occurs in sun-exposed areas of the skin. The skin contains a pigment called melanin, and excessive production of this pigment causes the skin to appear darker.
This commonly happens in women during reproductive years, or in the 2nd-3rd trimester of pregnancy in which case it is also called chloasma or mask of pregnancy. Complexioned individuals with Fitzpatrick skin type between grade iv-vi are the individuals most affected with this disorder. Melasma presents as irregular light grey-brown macules over the face, having serrated, irregular, and geographic borders.
WHAT CAUSES MELASMA?
- Exposure to UV radiation
- Pregnancy and oral contraceptives
- Thyroid dysfunction
- Drugs like phenothiazines
- Iron deficiency and anemia
WHAT ARE THE TYPES OF MELASMA?
Following are the types of pigmentation patterns in melasma:
- Centrofacial pattern is the most common and it affects cheeks, forehead, upper lip, nose, and chin.
- Malar pattern is a type where hyperpigmentation is present over cheeks and nose.
- Mandibular pattern is a type where the ramus of the mandible is involved.
With the help of Wood’s lamp examination, the following are the three types that depend on the extent and distribution of melanin in the skin:
- Epidermal Melasma– This type imparts a dark brown color which in most cases responds well to treatment.
- Dermal Melasma– Dermal melasma imparts a light blue-gray color that does not react to treatment.
- Mixed Melasma– Mixed Melasma imparts a brown-gray color present in both epidermis and dermis.
Wood’s lamp examination shows accentuation in epidermal melasma, which is not seen in the dermal type of melasma.
HOW TO DIAGNOSE MELASMA?
There can be multiple causes of pigmentation and to rule out some of the causes, the dermatologist will diagnose melasma by looking closely at the face and neck and will also ask for a detailed history of conditions such as onset and progression, associated symptoms, seasonal variation, history of cosmetic use and exposure to chemicals, history of pre-existing skin conditions, drug history, pregnancy, and menstrual history, past medical history, diet history, and family history. Be patient and help the doctor understand your pathology.
Your skin may also be evaluated under a dermatoscope, a patch test may be performed in case of suspicion of allergy from cosmetic and perfumery agents. The doctor may also order blood work up to rule out some systemic causes of pigmentation. Wood’s lamp examination and skin punch biopsy can be done to know the extent of pigment in the skin. Serial photographs of the first consultation and subsequent follow-ups may be done (maintaining complete privacy), this helps the client, as well as the doctor, understand the prognosis of the condition with an ongoing treatment plan.
Masi score can be done which is discussed on the first consultation itself. Masi score was developed by Kimbrough-green et al and is used for the assessment of melasma. Masi score is calculated based on three variables of pigmentation i.e. the percentage of the area involved (a), darkness(d), and homogeneity(h) of pigment, of which the severity is assessed in four regions i.e. forehead, right and left malar area, and chin. This helps to evaluate the ongoing treatment plan.
TREATMENTS FOR MELASMA
Treatment options for Melasma are as below:
- Discontinue using OCP, scented cosmetic products, and phototoxic drugs.
- Correction of anemia and other metabolic disorders is important.
- Broad-spectrum (UVA + UVB) sunscreens with SPF > 30 should be applied daily to minimize the reactivation of pigment-producing cells by exposure to the sun. UVA rays are responsible for stimulating the darkening of the skin. These rays can penetrate through window glass and clouds, making the use of sunscreen necessary for everyday use, even if indoors or it is cloudy outside. Sunscreen also helps decrease early signs of aging by UV damage. Sunscreens containing zinc oxide and titanium dioxide act as physical blockers to help shield the UVA rays from reaching skin cells. The higher the concentration of zinc or titanium oxide, the better it is.
- HQ – safely used since the 1960s, HQ acts as a blocker that acts on various steps of melanogenesis and helps slow down the pigment production in the cells. It can be used twice a day to help lighten the skin. It is available in the formulation of 4% HQ + 0.05% TTN + 1% HC acetate creams are known as modified Kligman’s regime which is helpful for the treatment of melasma, freckles, lentigines, and other pigmentary disorders.
- Retinoids – Retinol are some of the creams containing vitamin A retinoids that have been shown to help exfoliate the cells which contain the pigment, while also decreasing inflammation. They are used only at night.
- Azelaic acid –Azelaic acid 10% or 15% gel contains a natural skin lightening agent which is also a topical antibiotic and is safe to use during pregnancy.
- Kojic acid- Kojic acid is found as a fungal metabolite and helps to lighten skin pigment by inhibiting the activity of tyrosinase- a pigment-producing enzyme.
- Newer topical agents – containing tranexamic acid, plant extract like glabridin, hydroxystilbene mulberry, polyphenol, grape seed extract, aloe vera extract-aloesin, coffeeberry, catechin, gallic acid, and ellagic acid are useful.
- Corticosteroids may directly affect the synthesis of melanin, alter melanocyte function by inhibition of prostaglandin or cytokine production by various cells of the skin. It is used more often in conjunction with other topical therapies (e.g. tretinoin and HQ) but is notoriously associated with adverse effects like rosacea-like eruption with persistent erythema, pustules, and papules in a centrofacial distribution, perioral dermatitis, and atrophy. Hence, these should never be taken without the consultation with a doctor.
- Topical antioxidants – antioxidants, including Vitamin c, glutathione helps to decrease free radicals which are activating pigment-producing cells.
- Oral antioxidants i.e. Vitamin C, E, glutathione, astaxanthin, zeaxanthin, pine bark extract (pycnogenol) are all potent antioxidants for promoting healthy and clear skin.
- Niacinamide is a physiologically active amide of niacin (vit b3) also known as nicotinamide (3-pyridine carboxamide). Niacin is linked to the synthesis of NAD and NADP. It inhibits melanogenesis by interfering with pigment transfer between melanocytes and keratinocytes. Niacinamide increases skin lightness after 4 weeks of the treatment.
- Tranexamic acid is a plasmin inhibitor, commonly used as a hemostatic agent. It is also promoted as a systemic skin whitening agent, especially as oral or intradermal injections for melasma. Tranexamic acid stops ultraviolet (UV) induced melanogenesis. It is used at a low dose of 250 mg twice a day for at least 3 months for the treatment of melasma under a doctor’s guidance. Tranexamic acid is not to be taken by patients with acquired defective color vision, an active intravascular clotting condition, and hypersensitivity to tranexamic acid.
PROCEDURES FOR MELASMA
- Chemical Peels
In this procedure, layers of lightning agents and exfoliating agents are applied to reduce pigmentation. Chemical agents applied are non-toxic fruit enzymes popularly known as AHAS and BHAS in the cosmetic world. Superficial and medium depth include as below:
- Glycolic acid – a hydroxy acid, which at low concentrations gives an epidermal discohesive effect and at high concentration creates epidermolysis, typically resulting in mild flaking from days 3-5, thereafter leaving behind smooth glowing skin.
- Superficial GA peels in combination with modified Kligman’s formula and other peeling agents like salicylic acid peels – 20-30%, Jessner solution –resorcinol, salicylic acid, and lactic acid in ethanol, lactic acid peel, black peel, yellow peel, etc. can be useful for melasma.
- Deep peels are reserved for dermal pigmentary disorders and are generally not used for melasma as they may lead to hypo/ hyperpigmentation, scarring, keloid formation.
- Microdermabrasion can be performed, where a special lightening agent is instilled into the skin as the skin is simultaneously exfoliated, for a clearer complexion.
- PRP for face or ‘vampire facial’ made popular by the Kardashians is no doubt a miracle for melasma.
- Laser therapy which is available in the form of – Q switched lasers of various wavelengths:
- Q switched ruby laser (694nm)
- Q switched alexandrite laser (755nm)
- Q switched nd: YAG laser (1064nm)
- Fraxel 1927nm laser – thulium lasers
- Carbon Laser Treatments have been shown to lighten melasma in a series of two-five light treatments.
A dermatologist can differentiate between freckles, lentigines, Riehl’s melanosis, poikiloderma of Civatte, erythromelanosis follicularis of face and neck, lichen planus pigmentosus, nevus of Ota, erythema dyschromicum perstans, drug-induced hyperpigmentation which can all present as pigmentation over face and neck.
Let’s discuss some of them.
Freckles are small (<0.5 cms), discrete reddish or pale to dark brown macules with poorly defined borders in sun-exposed areas which are more common during childhood. Lentigines are present in large numbers and distinctive patterns. They are small (< 0.5 cm in diameter) circumscribed, brown to dark brown to black, variegated to uniformly colored isolated macules present on sun-exposed areas, or multiple lesions on any cutaneous surface including palms and soles.
This affects middle-aged women because of contact sensitivity to fragrance in cosmetics and physical irritation by UV radiation. This may appear as brownish-grey pigmentation over the greater part of face, forehead, temples with smaller pigmented macules – perifollicular, lying beyond the indefinite margins and may extend to chest, neck, scalp, occasionally hands, forearm.
Poikiloderma of Civatte
This affects middle-aged women and is caused due to sun exposure. It presents as reddish-brown reticulate pigmentation with telangiectasia, atrophy, and symmetric patches on the lateral cheeks and sides of the neck and upper aspect of the chest.
Lichen planus pigmentosus
This presents as hyperpigmented, slate grey to brownish-black macules over the face, neck, and upper limbs which can be more widespread. Mucous membranes, palms, and soles are usually spared. This is mostly diffuse, can be reticular, blotchy, and perifollicular.
Erythema Dyschromicum Perstans
Ashy dermatosis of Ramirez is an idiopathic acquired, generalized, persistent, pigmentary disorder commonly seen in young adults and is more common in females. Numerous macules of varying shades of grey, along with initial signs of inflammation with a red, slightly raised, and palpably infiltrated margin (erythema dyschromicum perstans) are observed. Trunk, face, neck, upper and lower limbs all may be involved. Macules may coalesce over extensive areas of the trunk, limbs, and face.
Nevus of Ota
Present since birth or develops during the first year of life and the second peak is seen in early childhood/ puberty. Nevus of Ota is more commonly present in females as extensive bluish patchy dermal melanocytosis in the area innervated by ophthalmic and maxillary divisions of the trigeminal nerve (around eyes, temple region, zygomatic region, forehead, eyebrows, nose, and usually bulbar, palpebral conjunctiva and sclera are also involved). Nevus of Ota is usually unilateral but if present bilaterally then it is termed as Hori nevus.
Localized or generalized hyperpigmentation can be caused by a variety of drugs namely- mepacrine, chloroquine, busulphan, methotrexate, hydantoin, tetracyclines, and psychotropic drugs.
Facial Hypermelanosis secondary to systemic disorders
Diseases like Addison’s disease, thyroid disorders, hemochromatosis, Cushing’s disease can also cause patterned and diffuse pigmentation. A dermatologist can look for the pigmentation in specific areas and may also order some blood work up to rule out such diseases.