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Author Topic: How to treat dermal melasma?  (Read 11963 times)

SarahVaughter

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How to treat dermal melasma?
« on: March 27, 2010, 08:45:49 AM »

>Dear Sarah,

>What can you recommend, if anything, for dermal melesma?

>I worry about creating added inflamation and yet I need greater penetration for my skin care products.

>Thank you in advance for any information you can provide


Melasma is one of the most difficult skin conditions to treat. It is caused by hyperactive melanocytes (pigment producing cells) resulting in the overproduction of melanin pigment. The origin of this hyperactivity is not fully understood, it’s believed to be a combination of genetics, hormones (estrogen) and sun exposure. High estrogen levels (due to hormonal contraception or pregnancy) usually triggers or aggravate this condition.         

Currently, doctors don’t know how to stop the overactivity of melanocytes. Thus they cannot treat the cause, only the symptoms.



Nevertheless, acid peels ( for examle  Jessner's solution)   can help. Melasma is frequently present in both the epidermis and the dermis ( Wood`s lamp can determine the depth of the pigment) so acid peels have only a limited effect. Old melanocytes will be replaced by new ones that are again over-active. Sometimes repeated stimulation induced by acid peels of the new melanocytes makes the melasma even worse - although this is highly individual.       

Tyrosinase inhibitors such as hydroquinone is currently the best treatment for melasma. They inhibit the enzyme that converts tyrosine to melanin. It occurred very rarely but in some individuals prolonged or/and excessive use of a high percentage hydroquinone (above 3% for 6 months) in combination with extensive sun exposure caused exogenous ochronosis – bluish black pigmentation.     

Tretinoin (Retinoic acid) usually improves melasma by increasing the turnover rate of new skin.     

Avoid exposure to sunlight as much as you can and use high factor sun blocks, preferably with zinc oxide or titanium dioxide (they block the entire UV spectrum). The downside is that they are reflectively white and will make your face whitish. Nowadays though, you can buy a sun block with nanoparticles of zinc oxide (micronised zinc oxide). This sun block is not white but transparent. There were some concerns about the safety of zinc nanoparticles since they, contrary to ordinary zinc oxide, could potentially penetrate deeply but after some studies showed it also stays on the surface, micronized zinc oxide was approved and it is considered safe.   

Alternatively you can add skin tone makeup to your zinc oxide sun block cream to make it less white.       

If you wish to stay in the sun for a long time and do not care how you look, buy a baby diper rash cream containing a high percentage of zinc oxide and totally cover the melasma with it. That will make your skin very white but it will totally or almost totally block the sun. Zinc dries up the skin so first apply some moisturizing cream and after that the zinc cream.

If you use hormonal contraception, consult your dermatologist and gynecologist whether it would be suitable to switch to non-hormonal contraception such as IUD, due to your melasma condition.       

Melasma creams typically contain a combination of a tyrosinase inhibitor, acid peels, tretinoin, sunscreen and sometimes a corticosteroid - which is an anti-inflammatory.     

A dermaroller for skin care product penetration (0.2 mm needles) should not cause any skin inflammation. If it does in your case, then use even shorter needles. There might be some short-lasting redness (just as it happens when you rub the skin) but that should disappear very quickly.

Dermal Melasma is in the dermis part of the skin and that is very deep. Anything acting superficially is not going to work. You have to get the products deep.

You can use a 0.2 mm dermaroller to enhance the penetration of hydroquinone to the dermis but do not do it for a prolonged time. The best protocol is  3 month on, 1 month off. You can use other skin lightening products with dermarolling.

Vit. C is a powerful antioxidant and in concentrations above 5 %, it acts as mild skin whitener. However, it can irritate the skin.

Apply tretinoin (Retin-A) once or twice a week on your melasma after dermarolling. Do it in in the evening because Tretinoin is light sensitive. If your skin becomes too irritated, apply it without rolling and less frequently.Be warned however that in some people this actually makes the melasma worse, because melanocyte activity can be increased by the skin stimulation from the tretinoin. This seems to be a genetic factor and unless you try it once, you won't know whether it applies to you. The same applies to laser treatment in melasma. Always do a small test patch first.



Lightening agents can't affect the existing pigment, it can only reduce the formation of new pigment. That is why it sometimes takes months to see effects.

Ablative procedures (such as microdermabrasion, acid peels etc) remove existing pigment but they cannot prevent the formation of a new one. They cannot go very deep due to danger of scarring and hypopigmentation. Dermarolling is not an ablative procedures (a dermaroller does not remove skin layers, it only make temporary microinjuries in the skin).



Since dermarollers speed up the skin's turnover it should improve Melasma by speeding up the sloughing off of skin including the pigmented skin. A short-needled dermaroller is useful for Melasma in the epidermis. A long-needled dermaroller could be an interesting option for dermal Melasma. The turnover of the epidermis is much quicker than the turnover of the dermis and ablative methods can't easily reach the depth of the dermis due to the risk of scar formation, so a dermaroller that can reach the dermis (> 0.5 mm) could be theoretically very useful for deep Melasma. However I'm not very keen on recommending it for Melasma because it causes short-term inflammation and it is likely that Melasma will reoccur and dermarolling will have to be repeated over and over for maintenance. If you decide to try it, do a test patch first.

  More details:  http://forums.owndoc.com/dermarolling-microneedling/Melasma-cure-and-dermarolling

     

Because inflammation seems to play a certain causative role in melasma and dermarolling might make it worse, I would be cautious using long needles (longer than 0.2 mm) due to the fact that they induce inflammation. There is not enough data available yet to make an informed judgment about using long needles on melasma.

 The problem with long lasting hyperpigmentation in Melasma, café-au-lait spots and other melanin related pigmentation is that the root cause of the pigmentation is unknown. It is caused by local overproduction of skin pigment melanin by pigment producing cells (melanocytes) but nobody knows why melanocytes produce an excessive amount of melanin in certain individuals. Thus, you cannot treat the cause but only the symptoms. That is why fighting hyperpigmentation is so difficult.

 You will manage to lighten your spot with melanin inhibitors, however it is likely that your melanocytes will keep on producing excessive amounts of melanocytes in that area. The reoccurrence of the hyperpigmentation does not always happen, however it is not uncommon.

     

There is a new skin lightening topical called Elure that works in a different way than hydroquinone.

   Elure contains an enzyme (  lignin peroxidase) that breaks down existing pigment. Hydroquinone prevents formation of a new pigment.

The results with Elure were disappointing in many cases and successful in a few. I don't want to comment on its efficacy because I truly can't say anything else about it except that it's extremely expensive.



When you use a sunscreen (I hope you do), use one that has only physical blockers and no chemical blockers.

    Physical ones reflect UV whereas chemical ones absorb UV and convert it to heat, which can make melasma and other pigmentation worse.

To read about the difference between physical and chemical filters, read this:

http://forums.owndoc.com/dermarolling-microneedling/Sun-protection-with-dermarolling

Pharmacies often sell a sunscreen with physical filters for people who are allergic to chemical filters.
« Last Edit: November 15, 2013, 03:24:10 PM by SarahVaughter »
I am not a medical doctor and my comments should not be considered medical advice.

The dermaneedling part of our site is http://owndoc.com/category/dermarolling/