This is the way of the future, namely a ‘cure’ for melasma. We don’t agree with the word ‘cure’, we prefer the term ‘long term remission.’ This concept is for those who can see past short term pigment fixes & would like to keep their pigment away, not just treat the signs of melasma. Remodelling is not for everyone, read more to see if this is right for you.
Why remodel?
The concept is simple. Pigment is reactive to aging. Reverse aging, pigment production is reduced, & hence melasma goes into remission. Pigment protects the underlying skin from UV and visible light, much like how tanning is a reactive mechanism.
Will all cases of melasma require remodelling?
No. If you truly have ‘hormonal melasma’, ie. High contrast sudden onset melasma when pregnant, most cases (50-60%), settle post-partum with normal melasma treatments (medical, laser, peels). This melasma group is usually younger (less than 30 ish) with MINIMAL to no photodamage & look good for their age.
The dermal remodelling group has a different phenotype. Typically, > 40 years old, lots of chronic sun exposure, wrinkles, & photodamaged skin. They look older than their age matched peers. Most will also exhibit elements of sun damage pigment that is not melasma- think age warts, freckles, sunspots & dermal pigment. This group may also exhibit pigment on the sides of the neck (poikiloderma).
Should you fall into this group, our clinicians will guide you accordingly.
The road map
Is complex for the patient, but straight forward to us. It consists of 4 stages & goes something like this-
Stage 1: pigment reduction.
This is what the patient sees & why they come in for. This stage can take 3 to 20 weeks, depending on the type of pigment (depth), genetic factors, environmental factors, patient insight & others. We can effectively reduce pigment in over 85% of melasma cases. Pigment reduction is achieved with peels, topicals, medical therapy, & lasers. A series of 2-4 sessions is conducted, 3 to 6 weeks apart.
Stage 2: building scaffolding. This is for cells to attach & the extracellular matrix to optimise. This involves a series (usually 3-4 injectable sessions that are conducted during the time of laser). This group of injectables prepare the bed for collagen, elastin & cells to attach to. Stage 2 can be implemented into stage one, depending on your long term goals, expectations & importantly clinical features.
Stage 3: remodelling & collagen stimulation. Stage 3 takes the longest to complete. It consists of changing the architecture of the dermal layers of skin & the cross talking of cells (collagen producing cells, mast cells, vascular cells, pigment producing cells & skin cells or keratinocytes). We employ a series of injectables & EBD or energy-based devices such as RFM, fractional non-ablative lasers, HIFU & non-focused ultrasound. A series of 3 to 6 sessions of each, spaced 4 to 12 weeks apart.
Stage 4 serotherapeutic intervention.
This involves the use of retinoids, & other topicals that reverse the aging process. Stage 4 consolidates steps 1-3 & is designed to provide longer term remission after the repair stages. Depending on your skin type, sensitives, age & goals, we prescribe a mix of-
- Pigment inhibitors
- Retinoids (prescriptive)
- Alpha hydroxy acids
- Antioxidants
- Senotherapeutic options
Can I skip the steps?
Yes, but the outcomes may not be as predictable. Each step builds upon the previous & is timed in a way to accelerate dermal remodelling.
Not everyone will require steps 2 to 4, it depends on your subtype of melasma & the degree of background photoaging.
How long is the remission & what are the chances of success?
Answer- variable & around 85%. Remission rates vary between 1 year to 10+, depending on the upkeep & intangible variables such as UV or IR exposure, as well as genetic factors. Success rates vary between 75 to 85%. Success is not absolute as there are still unknown variables when it comes to treating melasma pigmentation.
Flares are not uncommon
Here’s the caveat, dermal remodelling can be a rough ride with ups & downs. More powerful remodelling devices such as fractional lasers, HIFU, RF microneedling (think Potenza, Morpheus 8, Silfirm X) can remodel skin much better than fluffy treatments such as microneedling, however even with controlled heating of the dermis, flares may occur.
Flare ups can be symptomatically managed with stage one therapies, namely lasers, peels, & medical management of melasma.
I don’t want dermal remodelling, I just want a quick fix:
OK, so you really don’t want to invest in your skin & would like quick results. If this is the case, you’re reading the wrong article. As we’re specialists, we’re not here to judge, just offer you some guidance. If you’re after a FAST way to treat pigment (much like taking a can of spray paint to cover rust), here is the guide-
- Invest in sunscreen. I mean really invest. Twice a day, tinted, SPF 50, regardless of sun protection. You would be surprised that 98% of melasma sufferers don’t get past first base.
- Get a Cosmelan Peel or a Vi Precision Plus peel. Peels are a FAST way to reduce pigment. They work in 60% of cases, remembering you’re just a number in the algorithm of science. From there get some arbutin, t.acid topically, vitamin C, & azelaic acid. This may hold back pigment in 20-30% of patient. The majority of patients will rebound post peel (unless your melasma is truly ‘hormonal’).
- Cost vs benefit. If you don’t want to invest in your skin, buy a few nice pairs of shoes or a handbag, it may make you happier. The truth is that to reverse cellular aging in your skin gets very expensive, but the expense is relative. How expensive? Think a Birkin handbag expensive, or 4 LV handbags, or a dozen Jimmy Choos. It takes many sessions with a specialist to remodel skin as we employ lasers, injectables & many, many hours over 6 to 18 months. At the end of the day, we will achieve better skin, namely less photoaging, a reversal in cellular senesce, & improved skin quality. Pigment will also be dramatically reduced in addition to a marked reduction in your skin’s age. If you are motivated to reverse aging, we’re there to give our 100% to ensure your goals are met. The flipside? If you have a finite amount to spend & only focused on pigment itself, get a peel, cross your fingers it works & invest in sunscreens.
Retinoids & anti-aging skin care are over-rated
Yes, even prescription retinoids are overrated. As a rule, we only prescribe retinoids in the last 1/3 of remodelling cases. Why? Because they cause skin irritation that can compromise your treatment & in some cases lead to PIH or worsening of your melasma. Timing is critical.
Retinoids are incorporated in the latter stages of melasma prevention, along with antioxidants such as ascorbic acid, tocopherol & ferulic acid.
Lasers over Sylfirm X & RF microneedling
That’s our preference, not because we don’t have RF microneedling, it’s just that lasers are more efficient & effective in our hands. Don’t fall for the ‘basement membrane’ remodelling of skin using RF microneedling. All devices, if they go deep enough will achieve dermal remodelling.
Lasers, in particular non-ablative ones (in the correct setting), provide better pigment reduction, as well as collagen stimulation, as compared to RF microneedling devices. We employ fractional as well as full beam devices in many different wavelengths deepening on the degree of photodamage & your skin type.
- Lighter skin types with melasma & photoaging: thulium, diode lasers, RFM
- Darker skin types with melasma & photoaging: thulium & fractional pico, RFM
Why injectables?
Injectables provide an additional stimulus for collagen & extracellular matrix. For an effective anti-aging program, you need 3 things.
- The cell. That’s the hard one as we’re using your own cells in the skin to kick start the process. Alternatively, we can use your stem cells, or ASC. That gets crazy expensive as it must be done in hospital under sedation as we need to liposuction your stems (harvested from abdominal fat). So, for 99.99% of patients, it’s remodelling the fibroblast, endothelial cells & keratinocytes.
- The stimuli. Hence injectables that augment energy-based devices. More on injectables below.
- Scaffolding. This is achieved with PN or polynucleotides.
Depending on the degree of aging, we recruit injectables that are reflected in the literature. They include:
High & low molecular wight, heat stabilized Hybrid complexes of hyaluronic acid. The trade name is Profhilo. This works best as a hydrator, with very low levels of bio stimulation. Nevertheless, this can improve skin quality.
PDLLA: a new isomer of PLLA, also known as Aesthefill. This will be Australia in the next 12 months.
PDLLA +HA. This has a mix of hyaluronic acid & a “D” isomer of poly lactic acid. Also known as Juvelook 50 (overseas).
PLLA; tried & tested over the past 2 decades, best used as ‘filler’ or ‘tightener’ with very mild changes in skin quality. Also known as Sculptra.
What about exosomes?
Exosomes can work, but injectables work a lot better. It is all about probability, not the possibility of things working. Remember, you’re just a number. The whole aim of this dermal remodelling exercise is to provide you with the highest probability of
Summary
Dr Davin S. Lim
Dermatologist
This program is not for everyone; it is for the selected few who have –
- The ability to understand the process. For a clearer picture on who to treat melasma, you can ChatGPT the following prompts to get this idea. “Chat GPT; explain how to remodel the dermis in melasma.’’ Another prompt is ‘Chat GPT; explain cellular senesce and melasma.’’ Most patients cannot see past the pigment, if this is you, stick with a short-term pigment reduction plan.
- The financial means to commit to this program. It’s an expensive process, especially if a dermatologist is involved in your treatment. For dermal remodelling, I am involved in treatment (especially if injectables are employed). This means I am the one injecting as well as performing lasers. This is not delegated to my nurses as this process is tedious, requires lots of hand holding, reassurances & follow ups. In my experience if this work is delegated, it saves patients money, but I am called in for ‘follow-ups’ & checks throughout the process. This is inefficiency on my part; hence I combine my follow ups with treatment. Factor in injectables at between $990 to $1490 per session as well as low density lasers & devices that add another $990 to $1790 per session & the costs adds up. It is not for everyone.
- Time. It takes many sessions (think 8 to 20) over 18 to 24 months to achieve optimal remodelling of melasma. Most patients are in their 40s. It takes commitment to rejuvenate skin, with each procedure taking 20 to 40 mintues to perform.
References:
Targeting the dermis for melasma maintenance treatment
Han HJ, Kim JC et al
Sci Rep 2024, January 10; 14(1):949
Melasma relapse is common following the discontinuation of conventional treatments. Recent research highlights the role of dermal photoaging as a key mechanism in melasma pathogenesis, supporting the need for therapies that specifically target the dermis. This study evaluated the maintenance effects of microneedling radiofrequency (RF) in melasma management.
Participants received oral tranexamic acid and a triple combination cream for 2 months. During this period, one randomly assigned half of the face was also treated with microneedling RF. After stopping the conventional treatments, RF was continued monthly for six additional months on the treated side only.
Melasma severity was assessed monthly using the modified Melasma Area and Severity Index (mMASI) and L* values measured via chromameter. Fifteen patients enrolled, with eleven completing the 8-month trial. At the end of the initial 2-month treatment phase, all subjects demonstrated clinical improvement, with a 64% reduction in mMASI scores. Over the following 6 months, the RF-treated side maintained this improvement, while the untreated side progressively regressed, with ΔL* values returning to baseline.
These findings suggest that ongoing microneedling RF therapy can help sustain the benefits of conventional melasma treatments, likely through its protective effects on dermal remodeling.
(Clinical Trial Registration: NCT05710068, registered on 02/02/2023)
