Episode 23: Melasma

Melasma!
Welcome back to another episode of Just Laser It, where we break down the science behind the most common skin conditions and discuss the latest in cosmetic dermatology. Today, we’re diving into a particularly stubborn condition—melasma. Known for its characteristic dark patches, melasma can be incredibly frustrating to treat due to its complex triggers and chronic nature. 

While many of us may look to advanced treatments like lasers or chemical peels, topicals are actually the first line of defense and often the most effective way to manage this condition. In fact, relying too heavily on procedures may not always improve the appearance and, in some cases, can even make things worse. Join us to explore the challenges of treating melasma and why starting with the right topical regimen is critical to long-term success.

Let’s get started!

Thank you for your listenership!

Transcript

SOUND_PAD 0:03

Okay. Okay. Okay.

Minni Saluja, MD 0:13

Hi everyone. I hope you're well and welcome to another episode of Just Laser It and all things cosmetic. Can you know what I look forward to when I do this episode?

MIC2 0:22

forward to when I do this

Minni Saluja, MD 0:24

That's starting music. I kind of like

MIC2 0:26

kind of catchy. I always kind of do a little jig in my chair.

Minni Saluja, MD 0:29

I know it is kind of catchy for sure. Well today we're just going to jump right into our topic and our topic today is, is one of the two most challenging things to treat and that is, what would you say the two most challenging things are to treat?

MIC2 0:43

Why do you put me on the spotlight? Cause I have no idea. Just the whole aging process. How's that?

Minni Saluja, MD 0:48

Well, okay, fair, fair enough. But really in the clinic, two of the most challenging things are melasma, which we're going to talk about today, and cellulite, which we'll,

MIC2 1:01

I get it. Those are two good

Minni Saluja, MD 1:03

we'll kick that one down the curb, down the road for now. Down the curb. Is that what it's saying? We'll, we'll kick one down the road for now. Okay. So let's talk about melasma because we have, we have a fair amount of patients with this and melasma, as you know, is kind of a recurring type of pigmentation in the sense that it never goes away. It gets better. The worst times certainly are the summer times, and then there's kind of a seasonal improvement in the wintertime, and then it gets bad again.

MIC2 1:35

So it does kind of I didn't know that it does ebb and flow a little bit,

Minni Saluja, MD 1:39

It does ebb and flow, and the reason for this is, talking about what the causes are, and certainly UV light is one of the main causes of melasma. So, we have to definitely sun protect with with a potent sunscreen that covers both UVA and UVB. But you know what else causes it when we talk about light?

MIC2 1:59

Hmm. No.

Minni Saluja, MD 2:00

Visible light. So, when we're in front of computer screens with that blue light, that can worsen your melasma too. So, whenever I talk to patients in clinic, what we say is, Yes, you want to get a sunscreen that's got UVA, UVB protection, but you also want to get a sunscreen with a little bit of tint in it. Or you can put your own makeup, kind of intermix it into it as well, where it has iron oxide to help protect against visible light. So that's an important part of this as well.

MIC2 2:32

So that can help with the ebb and flow portion when it's. Again, when you

Minni Saluja, MD 2:36

Again, when you are really sun protecting, you're not going to get as much of that reactive phase as, as patients do in the

MIC2 2:44

part. So there's, it's multifaceted.

Minni Saluja, MD 2:46

It is. So that's, you bring up another part. So there's, it's multifaceted and certainly hormones can play a role in this as well. And in fact, we always hear about the, the mask of pregnancy. which is melasma. And typically in the third trimester, patients can start to have, start to see this even, even earlier too, but it's known kind of in the third trimester that we start to see this and men can get melasma too. And in fact, when men are treated for prostate cancer with certain medication that can also create a little bit of a melasma perspective as well. So it's not as common in men. It's definitely more common in females, but definitely hormones are part of it.

MIC2 3:25

So I get the, the pregnancy aspect but can it affect young people as well as old people? Or is there a general age that you'll start to see it,

Minni Saluja, MD 3:34

You'll start to see it more when you start to get the hormone perspective. So after puberty, you'll start to see melasma. And typically though, we start to see it more in pregnancy. Certainly birth control pills can also bring on a little bit of melasma, but typically it's more, I would say in our. Upper teens in 20 year old patients and onward.

MIC2 3:51

you wouldn't, would you develop it when you're 55?

Minni Saluja, MD 3:55

You could if you get on hormone replacement, you could, but, but most of the time, no, when you go through menopause, it starts to diminish. But what's interesting is that patients treated for menopause that were treated with estrogen only. So maybe they didn't have a uterus, estrogen only. They. would not get a rebound of melasma, but patients treated with progesterone only did. So while we always think it's the estrogen component, it very well could be more related to the progesterone component. And what's also interesting is patients with melasma, there's a four times higher increase of thyroid issues as well with melasma

MIC2 4:31

with melasma. Yeah.

Minni Saluja, MD 4:32

Yeah. So UV light, visible light, even heat. There was even some case reports of a baker who every time she opened up that oven, the heat perspective would also make her melasma worse. So there are different components that can kind of, that's what makes it so hard to treat is it's so systemic in nature from your hormones and also to the, to the fact that our light is everywhere. So that gets us to how do we treat this? What do we do for this? Because we often get. Phone calls where patients will say, can I get in for a laser for melasma? And I want to backtrack that because really the first line of treatment for melasma are topicals and sometimes that's the only line of treatment. And so. And what I mean by that is, for example, when we create this pigmentation, it's the melanocytes that are right in our basal epidermis that, that create this pigmentation. And there is a certain enzyme tyrosinase that we can inhibit with different medications. You've heard of hydroquinone before, and I'm gonna talk about that, but my, what I typically start. My melasma patients with, because I like to start one medication at a time, is I will start with Tretinoin. I'll start with a retinoic acid, which increases the cell turnover because this pigment is Created by our melanocytes, but then it's absorbed into our keratinocytes and our keratinocytes have to come up and shed, so I'll start with Trein, make sure that they're. able to tolerate that. And then I'll add

MIC2 6:08

what would indicate that you can't tolerate that?

Minni Saluja, MD 6:10

well, some patients do have a difficult time. Now, there is a retinitis dermatitis, which is a retinoid dermatitis, which is, it's rare. It's usually occurs because patients are starting off a retinoid too aggressively. Like they might be starting it off every night. You don't want to do that. Whenever you start a retinoid out, you want to start it out, maybe twice a week and build yourself up to it. So that might be the issue. And you always want to separate medications just to make sure that you know which one a patient is reacting to, but I'll start them off with that. And then I'll add a hydroquinone, which works on that enzyme that's the rate limiting step for creating the pigmentation. I won't go into all the chemistry of it. I won't bore you to it, but that's one thing, but I will say So, hydroquinone has got, has some controversy around it. In fact, it's banned in Europe. And part of the reason for it is that some of the studies, now granted, the studies that showed a cancer causing effect were in animals and they were high, high levels of hydroquinone. of hydroquinone. Those weren't correlative at all in humans. And there's been no reports of that occurring in humans, but it is banned in Europe. Safe utilization of hydroquinone means using products that are on the lower strength. You know, you don't want to use a 20 percent hydroquinone. There's a higher risk of, of issues. And one of the issues is darkening of pigment called ochronosis. So we typically will write for the 4 percent hydroquinone and we tell patients to use it for 2 months and stop it for 2 weeks. Use it for 2 months and stop it for 2

MIC2 7:50

these are both prescription.

Minni Saluja, MD 7:52

These are both prescriptions. Now you can get a ret a 3rd generation retinoid called Differin which is over the counter and You can certainly start there. It's a little gentler on the skin, too. So if someone has a real tough time with tretinoin, that might be an option as well. Very inexpensive over the counter. That is an option. Tretinoin is probably a little bit more potent, but that is something that that can be.

MIC2 8:14

you start somebody with topicals, when, how quickly would you be able to ascertain whether or not it's working?

Minni Saluja, MD 8:21

six weeks to three months. That's a good time period to really assess. I mean, don't expect any changes sooner than that, because remember a cell cycle is 28 days in a healthy individual. Otherwise that cell turnover, that epidermal cell turnover is much longer in, in older patients, unless you're on a

MIC2 8:37

so three months go by and you're really not staying, seeing any change.

Minni Saluja, MD 8:41

hang on, let's go back. Let's still go back. Let's go back to that. Why that two months on and two weeks off is important because you kind of want to reset your cells and allow them to. To not absorb too much of this hydroquinone, which can lead to this darkening of pigmentation. So you want to give yourself those, those breaks in between. But but so let's say, let's say hydroquinone is not an option. Let's say someone says, you know what? I, I really don't want to, I don't want to do this. What other options are there from a pigment lightener? There are, there are other options. Kojic acid is one, azelaic acid is another one. And another one is tranexamic acid. And tranexamic acid can be in a topical formulation. We have it in Pavisse, which is a sunscreen that also has pigment lighteners. It's got tranexamic acid also has niacinamide and licorice, but there's also oral formulations of tranexamic acid. Oral formulations can do a lot more than topicals. However, Oral formulation, so tranexamic acid works on plasmin and plasmin basically breaks down a clot. If I was to use it not for melasma, it's used in the gynecological world for patients who are hemorrhaging and they're given tranexamic acid to help them clot.

MIC2 10:03

So,

Minni Saluja, MD 10:04

We don't want to create clots. So the reason why I don't write for the oral medication is that there's a risk profile there that I'm not comfortable with. Now, It's written for, and, and no, a physician's not doing anything wrong by doing that, but it's just a risk profile that

MIC2 10:22

not even sure what you're saying,

Minni Saluja, MD 10:24

Tranexamic acid. Right. And that's,

MIC2 10:28

common name, or is that,

Minni Saluja, MD 10:29

that's, that's the name. Yeah. And, but you'll find this, you'll find them in skin ceutical products, you'll find them in, again the Pavisse. In the topical form. So that's where we are. Topical formulation is going to take much longer, might not even give as much, but it's a safer alternative than oral.

MIC2 10:46

a good place to start. Good

Minni Saluja, MD 10:47

Good place to start. And then one other thing to mention too is is you've heard about HelioCare, which is a leucotoma. It's a polypodium leucotomus, which is comes from a fern. That's an oral nutraceutical that helps to Photoprotect, it's got some antioxidant effects and that's good for patients with a melasma to take as well. It doesn't replace their sunscreen, but it might be something to take as well to help with it. So

MIC2 11:14

So, there are a number of different topical options.

Minni Saluja, MD 11:19

There are, well, I shouldn't say a number, but there's a good handful of them. Yeah, where they can utilize. And let's say we've primed their skin. We've made it so we're trying to minimize that enzyme that's creating the pigment and they say, what are my next steps? Well, that's when and they say I really want to do laser. Okay, here's the thing about laser There are no guarantees to the point where I tell patients a third of you may get better A third of you will stay the same and a third of you I will worsen with a laser because it can create post inflammatory hyperpigmentation in patients. It can just kind of recrudesce the melasma. So I'm not a huge proponent of lasers and we've got all sorts of different ones in the practice.

MIC2 12:05

is there a like a profile that would give you insight into who would be into those thirds?

Minni Saluja, MD 12:11

Not really, not really. Now the, the sometimes in patients, so if I see a lot of sun damage where I'm seeing a lot of solar lentigines intermixed with the melasma I might start with a low level IPL just to clean that up and patients will say, Oh my gosh, that's so much better. But I never do a second one because oftentimes melasma is epidermal and dermal. IPLs won't get to that dermal part, that stubborn part, that's deeper. It might just help with the superficial. So one treatment may help. There are some other devices which can deliver low level energy, Advo TX is one of them, a Pico Pulse laser with an alexandrite like PicoSure is one of them, but there are no guarantees with melasma and I'll tell you, even if we improve it, There's a high likelihood it's going to get worse again in the summertime. So there again, is that ebb and flow. We might be able to improve it for a small period of time, but it can certainly get worse.

MIC2 13:12

So it's temporary. I didn't realize that. I thought, you know, once you can kind of

Minni Saluja, MD 13:16

you can't cure it

MIC2 13:16

it's

Minni Saluja, MD 13:17

No, I mean, some melasma patients, and I'll say a very, a very small handful. We have made better and it's been more prolonged, but that's a small handful, Cain. That's not the norm.

MIC2 13:28

So really, it's just it's an ongoing battle.

Minni Saluja, MD 13:31

It is. It is. And I really think that the main component is. is really keeping up to date with the topicals, really hammering it in. And you know, I'm not a big product girl, but I, I believe in that pavis. I think that's important for patients with melasma to make sure they have, it's got antioxidants in it, it's got your bleaching and it's got your sun protection, but there are other ones too. If you don't have access to that, there are other ones just making sure that you get antioxidants, you get something for the pigment clearance and you're using a retinoic acid at night as well. So that's the ugly truth of melasma.

MIC2 14:07

and it's a it's an important truth for people to have or people to understand that if you take that laser step There's no guarantees and it could actually get worse not better. And there's

Minni Saluja, MD 14:21

You can improve the quality of the pores and all of that, but yes, the pigmentation, which is what they're sitting in my chair wanting to correct. I'm, I always kind of have to be really, really slow going with it. And, and if they say I've had three lasers before, four IPLs, and I tell them, no, I'm not even going to attempt one. There's a, there's a high likelihood that all the epidermal component is pretty much cleared away and you're not really going to see

MIC2 14:43

Is there a laser out there that, that people use a lot of for melasma? I mean, is there just kind of like a go to laser that maybe in, in just the, the, the common, you know, market, everybody thinks, oh, that

Minni Saluja, MD 14:59

Well, I think the PicoPulse lasers and the Q Switch lasers, I mean, back in the day Q Switch lasers were utilized. You know, Asians, Hispanics, these are the populations that have greater melasma. In Asia, low level Q Switch lasers and PicoPulse lasers are utilized. So they're kind of the ones that are the trendsetters for treating melasma. And again, it can be helped. But it's transient and there's a small subset that it can get worse. And on these Q switch and Pico pulse lasers, you could also see what we call confetti hypopigmentation where there could be areas of whiteness too. So those are things that can occur as well. So it's just really, really a difficult thing. Who knows, maybe there might be something that in the future that comes about, but for now it's a very difficult thing. And I think sun avoidance and really maximizing your UPF. Hats, you know, everywhere I go, Cain, I'm wearing one of those because I have a little melasma. I have a little bit on this, the side of my forehead. You know, you can see melasma, forehead, cheeks, upper lip, these type of areas, but

MIC2 16:02

Well, this is an important topic because I think it's one of those things that's very frustrating to people and they desperately want to see it improve. But I think it's important to have your expectations set that it may or may not improve. And even if it does improve to what you said earlier, it's likely transient and you're going to have, it's just going to be an ongoing battle. So just set that expectation.

Minni Saluja, MD 16:25

so whenever we look at literature reviews on melasma, it's, I don't want to look at three months. I want two year data, which you can't, it's hard to come by to see that. That's one place where menopause can actually work in our favor. If you're not taking any bioidenticals in that our melasma can improve when we get into menopause. So yay menopause. No, but that's all I've got for tonight. Okay. And any other questions or

MIC2 16:55

I actually learned a lot and I think it's important, like I said, that everybody understand the challenges of it and have the appropriate expectations in trying to deal with it.

Minni Saluja, MD 17:04

Yep. Well, that's it. Well, you're welcome. Well, everybody, I hope you have a wonderful night and we will talk soon. Bye bye.