What is the fastest way to treat melasma?

When do we advocate Cosmelan peels over lasers?

What are other types of chemical peels for melasma?

What is the best melasma treatment cream?

What over the counter creams for melasma?

What sunscreens do we recommend for melasma sufferers?

What types of melasma are resistant to treatment?

How do I get rid of the melasma mustache?

Should I avoid hair removal lasers if I have melasma on the upper lip / melasma mustache?

Does having superficial pigment mean 100% success?

What types of lasers for melasma are we experienced with?

What lasers are good for melasma?

How does dermal toning compare with pico lasers?

What is better for melasma- Picoway or Picosure or Picosure Pro?

is laser therapy for melasma a cure for this condition?

Does Fraxel treat melasma?

HALO laser- is it good for melasma?

What about vascular lasers for melasma?

Why is IPL a terrible treatment for melasma?

Can microneedling treat melasma?

Is RF Microneedling with Sylfirm X better?

Can LED flare up melasma?

How do we treat melasma in pregnancy?

What happens to melasma if I do not treat it?

Is there a link between thyroid disease & melasma?

Can melasma occur in men?

When do we biopsy (sample) melasma skin?

Do we treat international melasma patients?

A SummaryHow we approach melasma

Dr Davin Lim | Dermatologist
The Melasma Clinic, Brisbane | Sydney

The problem with melasma is that we still do not fully understand the cause. It is far more complex than the trio of genetics (DNA programmed) modified by epigenetics (environmental factors such as radiation & hormones. Though we can classify broad clinical variants like epidermal, dermal, & mixed melasma, & understand the histological features of this pigmentary disorder; namely increased number of melanosomes within various layers of skin, background photodamage, increased amount of blood vessels, basement membrane compromise & melanocyte drop out, the biochemical nature of melasma is harder to comprehend.

Over the past 10 years we now know the complexity & extent of cellular cross talking between just about every living cell type in the skin; from keratocytes & their cytokine expression, vascular endothelial cell, fibroblasts in the dermis, mast cells, lymphocytes & the culprit to blame for those who rarely understand this disorder- the melanocyte. Though we can individually target each cellular response; think vascular laser for vessel changes, antihistamines for mast cells, low density fractional RF or laser for elastosis & basement membrane changes, TXA for plasmin & VEGF-1 modulation, pico lasers for melanosomes & of course tyrosinase inhibitors of melanin synthesis, the sum of the parts does not equate to absolute control of this complex disorder. At best we can achieve 80-85% predictability in achieving a MASI improvement of 50% or more.

  • The difficulty is with photoprotection. Rumour has it that pre–WW 2 an experiment was conducted in Japan were a group of women with melasma were locked in absolute darkness for 30 days. In all cases they saw an absolute improvement in pigmentation, with zero treatment. This tale highlights the importance of strick an absolute photoprotection.
  • The problem with sun avoidance is twofold. Firstly, it’s almost impossible & secondly, it extends to beyond the UV & visible spectrum. Sunscreens, though useful do cut the mustard. UVB is simple to block, UVA shortwave is the same. Beyond 380 nm, more difficult. Close to 390 to 400, very difficult. Beyond UVA lies the HEV or high energy visible spectrum, the most important culprit is blue light.

Iron oxides incorporated into sunscreens is a novel solution, think Melan130, an excellent product bar two real world practical limitations. Firstly, the price. At around $120-130 for 50ml it is pricey. Factor is 3-5 ml per application, twice daily, you are looking at spending at least $100 on sunscreen per week, $400 per month or over $5,000 annually. That’s before the second SPF for sport & activity. Secondly, the fixed color tone of pre-packaged formulated iron oxide context. Melan130 simply does not suit Asian tones.

The action spectrum of melasma that is rarely discussed is of course, near IR or infrared. Why? Because it is very hard to practically protect against. IR is seen (or more accurately present) in our daily spectrum of radiation (UVC is attenuated by the atmosphere). IR is reflected off bitumen, water, glass & most importantly in the kitchen. Saunas are also sources of infrared light. The almost impossible melasma patient to improve? Cooks. The high amount of IR exposure stimulates pigment cells to produce melanin in far greater quantities than even the most potent enzyme blockers can inhibit.

Unless you live behind plexiglass, titanium coated film or aluminum foil, IR is very hard to (totally) block out.

The challenges of melasma we face is the amount of misinformation & misguided treatments. Putting aside ‘home remedies’ that are trending in third world countries such as India-Asia (diets, supplements, lemon juice & herbs), in Australia the three most common mistakes we see include –

  • Aggressive microneedling. Throughout this site you would see that we discourage deep microneedling, as opposed to encouraging sensible home microneedling to potente the absorption of skin care actives. The problem with microneedling is the widespread use of this skin rejuvenation technique to cure just about everything from pigment, scars, wrinkles, enlarged pores, skin laxity, hair loss, & more. Though it is use for some skin ailments, scars in particular, sticking deep needles in melasma pigment is counterproductive, often making our job harder as pigment is a.) more resistant to pigment, b.) pigment is pushed deeper in the skin & c.) patient is more nervous as previous treatments have either not worked, or made worse. If you insist on microneedling, do it at home with a stamper that is less than 0.2 mm long.
  • Wrong lasers or equipment. Again it is the commercialism of the beauty industry of using one device to treat everything. It is most prevalent in chain clinics whereby turnover is required with standard operating protocols that are skewed towards the lowest common denominator or more fairly the least trained operator. Think IPL or Sciton BBL – Forever Young. Whilst this is an awesome treatment for non-melasma pigment, the high heat output of IPL worsens melasma in over 80% of cases.

The same applies to over use of fractional lasers such as Fraxel, Moxi, Frax 1940, LaseMD, & even Clear + Brilliant. These lasers are awesome for treating sun damage & age spots, but the high heat output of the 1927 thulium – diode wavelength that targets water in the epidermis will often flare melasma. The question is, why are these devices reported to help treat melasma? It is the context of application. Low density low fluence, multiple sessions can do it, however the fact remains that side effects & clearance rates are much higher & much lower compared to pico lasers. Again it is about applying the correct method to match a condition, not the other way around.

The real world management of melasma can be challenging. As previously mentioned, inappropriate treatments will place patients on the back foot. Two other rate limiting factors come into play. Firstly, co-existence of other skin conditions that occur with melasma. Classically, Hori, dermal dyschromia (common in Asians) as well as freckles & age spots. Although not diagnostically or therapeutically challenging, it can blow out the treatment times by a factor of 2-4, especially if Hori is seen. We use different laser systems in different settings to manage deeper dermal melanocytosis.

Lastly, dermatologists have this saying; melasma humbles even the most astute physician. This means, even though all the stars are aligned; superficial melasma, absence of photodamage, absence of vascular component, no previous treatment, supremely compliant patient who uses sunscreen religiously, avoids the sun, wears hats & even a full face visor, no exposure to heat, & on gold-standard therapy with tyrosinase inhibitors, vascular modifiers, & pico lasers, our hit rate is 80-90% at maximum. This goes to show that we are not quite there yet as to fully understanding this disorder.