Cosmetic Dermatologist

Summer…..ah, yes. Lazy  sunny days in the park/at a festival, glamorous white linen separates, glowing,clear skin (see impossibly leggy Alexa for a sickening example)….except that so often it isn’t clear. Its completely ruined by big, muddy, brown splodges on the forehead, cheeks, upper lip and chin-the so-called mask of pregnancy, melasma. In fact, it may well present itself at a time when you’re not remotely pregnant-it occurs in those who are genetically susceptible (commonly affected races include Asian, Hispanic and African-American)and is triggered by UV exposure; hormonal influences may also play a role but men do suffer from melasma too, so its not the whole story by any means. Similarly, whilst melasma may develop during pregnancy or after starting the oral contraceptive pill, it rarely disappears once the pregnancy ends or the pill is stopped. I think of this condition as one of melanocyte instability-those pesky pigment-laden cells (which are there to protect our epidermis from damage due to sun exposure) are all-too-easily tickled into dropping melanin in an untidy fashion leading to the aforementioned splodges.

Treatment is a challenge-the first step is sun protection. All year-round. Skin  biopsies of patients with melasma typically show evidence of damage to the elastin fibres which is associated with sun exposure. So don’t sun-bathe. Please. And wear proper amounts of broad-spectrum SPF 50 sunscreen every day, re-applying if in direct sun-light (but please, avoid sunlight during peak hours of 11-3pm).

The next step is to use a skin-lightening agent. This will work best for those with melasma in just the upper layer of the skin, the epidermis; however it can affect either the epidermis or the dermis, and sometimes both. Just to be tricksy. Skin-lightening agents attract a lot of controversy-but they are an essential part of the armementarium in treating melasma.

Options include:

1) Hydroquinone

A highly-effective bleaching agent, and used in concentrations of 2-4%. It received negative publicity because of cases of ochronosis largely reported in South Africa-but these cases used higher concentrations of non-prescription hydroquinone without physician supervision for many years. Treatment response plateaus after 6 months so its important to use it cyclically to maintain its effects.

Its often combined with other agents-retinoic acid and sometimes topical steroids-for maximum efficacy. Downside-it can be irritant.

2) Azelaic acid

This useful ingredient is a pigment suppressor, rosacea tamer and a comedone-preventor….so a real multi-tasker. Its effect is probably better than low-strength hydroquinone  when used twice daily.

3) Arbutin

Derived from the bearberry plant, this has a similar structure to hydroquinone.

4) Kojic acid

It’s limitation is its tendency to irritate-but again, a good alternative to hyroquinone and again, probably equivalent to using 2% strength.

Peels and lasers can be used……but caution! Any form of injury or trauma can potentially ‘shake’ the volatile melanocyte and trigger a melanin-spill. If you do embark on these treatments (and they can work well in those with deeper melasma), only do so with someone who is experienced at the procedure in this difficult clinical setting. And stabilise your melancytes first with appropriate bleaching creams. The Obagi Nuderm system is my preferred weapon, but the Epionce system (based on azelaic acid and botanical agents) works well too.

Or you could become nocturnal. It’s a thought…..