Updated: May 8, 2020
“Mommy you have dirt on your face,” my son said that to me when he was about two years old. I proceeded to find the nearest mirror only to discover that virtually overnight I had developed a particularly ugly patch, in a not-so-lovely shade of brown, making its way across my cheek. I remember when I was a kid telling my mom that she had so many freckles that they connected and made one big patch of brown. It seemed like an innocent comment at the time, but now I realize karma got me good for that one because, oh my, how I battle the brown! Melasma, say it with me, melaaaaaaasma sounds like it should be the name of some super decadent gooey dessert, but actually it is the name of a hormonally driven skin condition that causes patches of unsightly pigment that apparently looks like dirt to small children. This type of pigment is one of the most stubborn and complex skin phenomena that I treat.
Sun exposure and hormonal stimuli, like pregnancy, the use of oral contraceptives, and hormone replacement therapy in a genetically predisposed individual can lead to the development of melasma (aka: chloasma or “mask of pregnancy” when developed while pregnant). Typically, hormonal pigment is seen on the forehead, across the cheek bones, bridge of the nose, and on the upper lip and chin (basically 90% of your face). In particularly uncontrolled cases, it can present in other areas of the face and some parts of the body. The condition is mostly found in women, but it is possible for men to develop melasma too. It is more prevalent in darker skin, and is thought to be linked to Estrogen and Progesterone sensitivities. Melasma is not physically harmful but the emotional toll of having patches of pigment can be considerable. While there is no cure for melasma, there are several ways to treat it. Be prepared for a fight though. Hormones are tricky, and so are the pigment patches they stimulate.
When treating sun damage, or hyperpigmented spots resulting from photo stimulation alone, we can use pulsed light therapies like IPL and BBL to efficiently and effectively break down pigmented lesions. Unfortunately, though, heat exacerbates melasma, and these treatments produce a lot of heat! Pulsed light, radio frequency, and laser therapies could actually worsen melasma instead of improving it because of all the heat they yield. There are some devices on the market that claim to effectively treat melasma despite the heat that they produce. In my experience, these devices clear the skin significantly at first, but then there is a rebound effect and pigment comes back with a vengeance. My go-to treatment is the heat-free option of microneedling with topical lightening agents and peels. When this treatment is administered correctly, it produces beautiful and predictable results. I typically do a series of three spaced 4 weeks apart then 2 maintenance treatments per year in Spring and Fall. There is significant peeling with this treatment that can last for 5-7 days, but the amount of correction we see makes it worth a few side-eye glances from coworkers.
Following treatment, patients should do their best to stay out of the sun, or protect with SPF of 30 or better when that is not possible. Wearing a wide-brimmed hat for additional protection, if you plan to be out for longer than 20 minutes, is a good idea. Remember that heat will increase and darken your pigment. Try to avoid prolonged exposure to heat as well (not the easiest task in Arizona). Those suffering with melasma will notice that working out or raising the body's core temperature will also make your melasma more visible. With proper in-office care and at-home maintenance patients can enjoy long- term clearing of melasma.
Your home care regimen should include products that contain active prescription-grade lightening ingredients. There are two that I recommend. One is 4% hydroquinone which can be found in products like ZO Pigment Control Crème 4% HQ - RX. Hydroquinone is a slightly controversial ingredient because it is found to be carcinogenic when ingested in laboratory mice, but not when applied topically. When applied to the skin, it acts as a tyrosinase (chemical messenger for pigment production) inhibitor but cannot be used long term because the body eventually acclimates to it and there is a rebound effect, making pigment more pronounced. We combat this rebound by cycling patients on and off the product. Three months of twice daily 4%HQ application then two months of non-hydroquinone lighteners like arbutase or azelaic acid is standard.
Another option is Cyspera Intensive Pigment Corrector which contains 5% Cysteamine Hydrochloride, a chemical that already exists in the body and is richly present in human breast milk. This ingredient’s mechanism is, again, to inhibit tyrosinase, but it is also blocking melanin synthesis by inhibiting peroxidase, scavenging dopaquinone, chelating iron and copper ions, and increasing intracellular glutathione. I know, I know, I’m geeking out again! Cyspera has no known side effects and has only three contraindications: vitiligo, pregnancy, and breastfeeding. Most importantly, in a randomized, double blind placebo-controlled clinical study, it significantly outperformed 4%HQ. Personally, I think Cyspera Intensive Pigment Corrector is the better way to go, but it’s expensive, smells like Ogilvie Home Perm, and some of my patients are just really attached to their hydroquinone. So we have choices.
Clearing your pigment will not only give you a boost in self-esteem, it will also give your skin more reflectivity! Pigment absorbs light rather than reflecting it, making the skin look dull and sallow,enhancing fine lines and wrinkles. Nobody wants that. Talk to your aesthetician to find out how he/she treats melasma. Be wary of any treatment that leaves the skin hot or sunburned feeling. Don’t be afraid to ask for a heat-free alternative. Be vigilant about sun and heat protection and consistent with your treatments and products, and you will find a new level of confidence with your glowing skin.
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