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Why there are no quick fixes for blotchy skin

Melasma treatment takes time because it may have underlying causes that are genetic or hormonal in nature

Patients with melasma on their cheeks. Optimal management of difficult cases usually includes combination therapy where a topical treatment inhibits melanin production while a laser procedure accelerates melanin removal.

AS I review Madam A one month after her first laser session, she queries: "Doctor, why isn't my melasma cured?" I proceed to reiterate what I had already told her previously during my consult with her, that melasma is a chronic problem and its management involves a period of regular follow-up.

This is a common skin pigmentation problem and there are reasons why there are no quick fixes for the blotches of darkened skin.

Melasma affects more than 45 million people worldwide; every year in Singapore, the National Skin Centre sees about 1,500 cases of women who suffer from this condition.

It causes blotchy, symmetrical, brown patches, usually on the cheeks, nosebridge, and sometimes on the forehead, chin and other parts of the body that have significant exposure to sunlight, such as the arms. While melasma isn't painful and doesn't pose any health risks, it causes significant emotional distress for women who develop these dark patches on their faces. The condition can be difficult to treat and it can last for years.

Melanin is what gives our skin its colour. When there is overproduction of melanin by our pigment cells, called melanocytes, it produces unwanted pigmentation in our skin.

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Melasma is more common in darker skin types, such as Asian skin, compared to lighter skin. It generally starts between the age of 20 and 40 years, but it can begin in childhood or later in life. Women are far more predisposed to getting melasma. Also, 55 per cent of people with melasma have a blood relative with the condition.

Triggers of melasma

* Hormones: The use of birth control pills and hormone replacement therapy may worsen melasma. Commonly, pregnancy triggers melasma due to an increase in hormones, and this is termed the "mask of pregnancy". Menopause may also cause melasma to appear in sites other than the face, for example, on the neck and arms.

* Sun exposure: The sun is a major culprit in triggering melasma. Ultraviolet (UV) rays from the sun stimulates the melanocytes to produce more melanin. In fact, just a small amount of sun exposure can make melasma return after fading.

It is the main reason that many people with melasma get it again and again.

* Skincare products: If a product irritates your skin, your melasma can worsen due to inflammation.

The first step in treating melasma is confirming with a doctor that your darkened skin patches are indeed melasma, and addressing any underlying triggers. Eliminating or minimising triggers is very crucial to treating melasma, or else you will be running on a hamster wheel.

Treatments for melasma include topical, oral, procedural and combination treatments. These are aimed at various aspects of the root cause of melasma, including sun exposure, inflammation and pigmentation.

One of the most crucial preventive treatments for melasma is sun protection. This means wearing sunscreen every day and reapplying the sunscreen every three hours.

Sunscreen alone may not give you the protection you need, so combine it with a wide-brimmed hat and an umbrella when you are outdoors. Wear sunscreen that contains physical blockers, such as zinc oxide and titanium dioxide, which will stop all the UV rays and different wavelengths from coming through, and hence provide a better protection against UV rays.

Topical treatments for melasma typically are creams or serums containing hydroquinone, ascorbic acid, corticosteroids and tretinoin. Newer treatments such as tranexamic acid, with fewer side effects and proven efficacy, may also be used. These work by producing anti-inflammatory, antioxidant effects, and inhibit production of pigment by melanocytes. Most of these formulations are available only in clinics.

Hydroquinone 2-4 per cent may be applied to pigmented areas at night for three to six months. This may cause stinging and redness in 25 per cent of patients. It should not be used for prolonged courses or in high concentrations as it has been associated with ochronosis, a bluish grey discolouration.

Tranexamic acid has also been used for melasma as a cream with good effect. Its mechanism of action is proposed to reduce blood vessels supplying the melanocytes and also reduce melanin production.

Ascorbic acid (vitamin C) inhibits pigment production. It is generally well-tolerated but highly unstable, so it is usually combined with other agents.

Topical corticosteroids, such as hydrocortisone cream, may work to quickly fade the colour and reduce the likelihood of redness and irritation caused by other agents. Potent topical steroids are best avoided due to their potential to cause adverse effects.

Topical therapy takes at least three months or longer to see skin lightening and those patients who are interested in a more rapid response could consider adding other treatments such as oral or laser therapy.

Oral treatment for melasma can be tried with tranexamic acid, to inhibit melanin synthesis. Side effects such as headaches, abdominal bloating, menstrual irregularities, and deep vein thrombosis may occur. People with a background of ischaemic heart disease, stroke, deep vein thrombosis and kidney problems should not take it.

Procedures for melasma

* Chemical peels: The addition of chemical peels to a topical treatment regime helps to accelerate the elimination of pathways for melanin production. Superficial peels such as glycolic acid and retinoic acid are typically selected because they tend to have the least risk of complications and exacerbation of pigmentation if there is too much inflammation or irritation.

Peels have been shown to be effective, especially when used in a series of treatments. They remove superficial layers of the skin and the pigmentation contained in them.

However, chemical peels may cause melasma rebound or post-inflammatory hyperpigmentation (PIH) due to irritation or inflammation. PIH occurs when there is excessive stimulation of the melasma, causing pigmentation to be darkened transiently.

* Laser and light treatments: To accelerate the rate of melasma improvement, laser treatments can be used. Low dose Q-switched Nd:YAG 1064nm lasers destroy melanosomes, which is the site for production, storage and transport of melanin.

Yellow lasers vapourise melanin and also target blood vessels supplying the melanocytes, which will improve results and prevent relapses. Picosecond lasers, non-ablative fractional lasers and intense pulsed light are also commonly used.

Optimal management of difficult cases should include a combination therapy where a topical treatment inhibits melanin production and a laser procedure accelerates melanin removal.

Counselling prior to treatment is very important - melasma has underlying genetic, hormonal, sun exposure and inflammatory causes which we are unable to completely eliminate, and hence, procedural treatments are not cures for melasma but can only lighten the affected skin after a series of treatments.

Recurrence, PIH, and rebound hyperpigmentation may also occur. Regular follow-up with a doctor for your melasma is crucial in producing sustained lightening effects.

This series is produced on alternate Saturdays in collaboration with The Aesthetics Medical Clinic.

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