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Mastering the Treatment of Melasma

By: Raffy Karamanoukian, MD, and Hratch Karamanoukian, MD
Posted: February 28, 2012, from the March 2012 issue of Skin Inc. magazine.
Because melasma is a chronic condition with high rates of recurrence, clients who are predisposed to developing melasma may find current treatment modalities needlessly frustrating and difficult.

Because melasma is a chronic condition with high rates of recurrence, clients who are predisposed to developing melasma may find current treatment modalities needlessly frustrating and difficult.

Melasma is a benign skin disorder characterized by irregular patches of pigmentation on sun-exposed areas of the face. The condition is most common in adult females, who comprise approximately 90% of known cases. Although there are many clinical manifestations of melasma, it is generally considered to be a chronic condition with progression of disease if left untreated. Melasma occurs as a result of upregulated melanocytes that produce irregular patches of hyperpigmentation on the skin.

Understanding melasma

Melasma is a chronic condition that primarily affects healthy women of childbearing age. It is believed that a combination of sun exposure, hormones and genetic susceptibility lead to the development of the characteristic blotchy skin associated with melasma. Traditionally, its treatment has been based on four distinctly different, but interrelated modalities:

  1. Avoidance of UV exposure;
  2. Topical regulation of melanocytic activity;
  3. Selective light-based and laser-based photothermolysis of melanocytes or melanin; and
  4. Chemical or mechanical exfoliation.

1. Avoidance of UV exposure. Minimizing UV exposure begins with the use of sunscreens, and the avoidance of direct and indirect sunlight. Clients should be advised to restrict direct sun exposure during peak hours and apply a physical sunscreen with at least an SPF of 30. By avoiding direct UV exposure, clients avoid unnecessary upregulation of melanocytic activity.

2. Topical regulation of melanocytic activity or melanin production. This is a mainstay of treatment. Common ingredients to help treat melasma include kojic acid, arbutin, hydroquinone and retinoids. The mechanism of action includes enzymatic blockage of melanin production, nonselective inflammatory mediation, tyrosinase-inhibition, stimulation of keratinocyte activity, and mediation of melanosome maturation and transfer. Increasingly, however, clinicians have noted that some active ingredients may not be as dose-dependent as previously thought. Stronger concentrations of active ingredients may lead to higher adverse reactions, with equivalent responses to treatment.

3. Selective photothermolysis. Selective photothermolysis of melanin pigment or melanocytes can be achieved through the use of nonablative lasers and intense pulsed light (IPL). These treatments target either the melanin granules or the upregulated melanocytes. In theory, light-based treatments have the potential to irreversibly inhibit melanin production, thereby causing hypopigmentation; or paradoxically, induce melanin production, thus worsening the degree of hyperpigmentation.

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