Melasma - Protocol for Problematic Pigmentation

9/28/2011 Osmosis Skincare 1 Comments

MELASMA, also known as the “mask of pregnancy,” is an increasingly common condition and, unfortunately, a difficult one to correct.  Debates exist as to the cause of the problem, but there appears to be a clear link to hormone abnormalities and associated physiologic changes.

Regardless of the internal cause, new topical strategies have been proposed to address cellular dysfunction, and some supplements have shown tremendous promise in improving melasma. This article discusses the long-term effects of existing protocols and what the future looks like for this challenging skin condition.

Potential Causes

Melasma has been connected to the use of birth control pills: one third of all women on birth control develop melasma. Pigmentation from BCPs and pregnancy are likely related to hormone imbalances. Whether the cause is a liver disturbance and the associated hormone conjugation abnormalities, excess hormone-induced fungal overgrowth affecting the melanocyte or simply hormone-induced melanocyte dysfunction has yet to be determined. Research suggests that the link is stronger with elevated progesterone, since menopausal women receiving estrogen do not develop melasma unless progesterone is added to their protocol. Other research has demonstrated that melasma sufferers have an up regulation of estrogen receptors on melanocytes.

Today’s Treatments
Regardless of the cause, the lifetime of significant disfiguring pigmentation impacts the daily lives of melasma sufferers. In addition, their skin is subject to constant abuse from lightening products, steroids and acids—all in an effort to moderate the amount of pigment produced.

Hydroquinone or hydroquinone plus a steroid are two of the most commonly prescribed approaches to melasma. While modest success is achieved from these regimens, the toll placed on the skin does not justify the results. Most physicians admit that neither of those ingredients should be used for extended periods of time—and yet most women do not stop using them in fear of the return of hyper-pigmented lesions. Hydroquinone is toxic to the skin but acts as an effective tyrosinase inhibitor. On one hand, it stimulates melanin (through additional inflammation), but blocks it on the other. The results are often mixed because of this conflict. Presumably, for that reason, a steroid was added to reduce the inflammation associated with hydroquinone. The steroid helps to slow melanin more than hydroquinone alone, but it also thins the skin and promotes scar tissue formation. Hydroquinone can also cause additional, permanent pigmentation through extended use called exogenous ochronosis.

There are other lighteners like kojic acid, arbutin and Sepiwhite but their efficacy is limited by the constant hormone-based stimuli that increase melanocyte activity. Another alternative treatment is repeated laser procedures, which are temporary, painful and expensive to maintain. Peels can certainly cause temporary lightening, but they can also worsen the condition if they are too inflammatory.

Aging Effects of Medication

In addition to the direct inflammation from the ingredients, there is a costly, indirect problem that is rarely discussed—the aging effects of long-term lightening protocols.

Let us examine the aging cycle of an African American. Research shows that compared to Caucasian skin, their skin has an average level of protection equal to SPF 13.4. It makes sense that their inherent SPF protection is the primary reason why most African American clients do not develop wrinkles until 60-plus years of age. We must assume that the secret belongs in the darker skin’s ability to control the level of free-radical damage.

So then what is the effect of a protocol that results in a significant reduction in melanin? I suppose we could argue that this patient has an “SPF 13.6.” This means that clients with reduced pigment production (roughly 40 percent, if effectively suppressed) will burn 13 times faster than others with similar skin types and normal melanin levels. For this reason, it is likely that long-term tyrosinase inhibition (especially if a steroid is included) significantly accelerates aging.

Dealing with Melasma

Most patients with melasma follow anti-fungal protocols with supplements like caprylic acid and prescription anti-fungals. These clients should also adhere to an anti-fungal diet, which includes digesting only complex carbohydrates, keeping other carbohydrates to a minimum, and avoiding yeast-filled products like bread and mushrooms. I have personally witnessed a number of success stories utilizing this diet strategy, but it rarely seems to eliminate all of the excess pigmentation entirely.

So what else can help?

My recommendation for melasma, which is also effective for most other skin conditions, involves avoiding daily exfoliation and promoting a healthy epidermal barrier. This should be a logical approach considering the reduced inflammation that results from it—but very few skin care lines actually agree with the philosophy. Simply put, every time we exfoliate, we increase free radical damage and the likelihood that more pigment is being stimulated. By encouraging turnover through dermal stimulation, something I call “natural exfoliation,” you achieve a better outcome with much less free radical damage and pigment stimulation.

Internal Strategies

Melasma is a lifelong challenge that is often quite socially limiting. The current options commonly employed should not be used for an extended period of time. However, the future looks bright. Focus your clients on internal strategies to assist their topical results. It is certainly better than relying solely on the prospect of lifelong, marginally effective skin creams. With that said, the future of topical therapies is brightening quickly as “zinc finger” technology makes its way into more products.

--This article, written by Ben Johnson, MD, was originally published in Les Nouvelles Esthetiques & Spa – April 2011. Click here to visit their website and view the full article.

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