Put simply it is genetic. Technically it’s genetic with a drive from external factors including UV, hormones, heat & iatrogenic causes. 

The idea of treating melasma is to decrease the output of melanin (pigment) from melanocytes. Sounds easy, but it is far, far more complicated. There are many factors that dermatologists consider including contribution from blood vessels, basement membrane integrity, hormonal input & sources of radiation (UV to IR spectrum).

Lasers employed for the treatment of melasma do one of five things-

1. They reduce pigment transfer from the pigment cell to the skin cells. It is called selective photothermolysis, in other words putting the pigment cell to sleep & not beat the sh*t of out if.
2. Increase absorption of topicals that quieten down the pigment cell. An example is low power, low density thulium lasers.
3. Repair the leaky basement membrane. High risk, but in theory it can be done.
4. Reduce the blood vessels that interact with pigment cells. This is the job of vascular lasers & yellow light lasers.
5. Encourage transepidermal & dermal exfoliation of pigment. This was how 1550 Fraxel got approved. Looking back, it was a silly way of treating primary melasma, but it can be used as last line treatment.

Picosure Pro is the best laser for melasma pigment (better than Picoway). It provides super fast clearance of melasma within 5 to 10 days in one single treatment, however a series of 4-5 sessions will give better results.

Pico lasers can deliver laser light that breaks up unwanted pigment with super high energies but very little heating- that is the key in treating melasma pigment.

Pico lasers are most useful for treating all forms of pigment, including melasma. Lasers should always be combined with medical therapy for optimal results. Using appropriate technology we can clear most, but not all cases of melasma. Our hit rate ranges from 80 to 85%.

Maybe you don’t have access to lasers. Peels can help. The thing to remember is that peels must be gentle. My preference is glycolic or lactic acid, low concentration at 15 to 25%. Peels work by exfoliation of pigment, they do not suppress melanin production, hence they are not my preferred method.

There are novel peels. I use these peels if-

1. Patients cannot have lasers, namely geographical constraints.
2. Melasma is primarily epidermal, or mixed.
3. The patient understands photoprotection
4. Ideally patients are on vascular moduators

Tranexamic acid is a plasminogen & vascular modulator. Most dermatologists use this tablet to reduce vascular input to your pigment cells. This is a prescription tablet. Your specialist will take an appropriate medical history to ensure you do not have any contraindications. Tablets are far more effective than creams.

I may be able to help you, depending on how bad things are. If your melasma is dermal (grey, dusky), it is much harder. I would rather treat epidermal flare ups from IPL compared to deep microneedling exacerbated dermal melasma.

I can improve 80-90% of cases. Despite optimal sun protection, pigment inhibitors, tablets, lasers & peels, 10-20% of cases of melasma are resistant.

We are in an infinitely better position to treat melasma now than ever before. Perhaps in the next decade more research will reveal better solutions for resistant melama.

50 percent of pigmentation can fade with proper sun protection. This means hats, umbrellas, tinting as well as sunscreens. Use a high factor SPF 50+, minimum of four mls a day. You should use a 50ml tube within 2 to 3 weeks.

If you don’t take sun protection seriously you are wasting your time, effort and money trying to fix your pigmentation.

Hormones & heat. Melamsa can worsen with pregnancy & IVF. Additionally, heat generates IR or infrared radiation. This can worsen pigmentation. Sources of IR include cooking and saunas. You don’t really need to worry about computer screens as a primary source of heat & radiation until you get your photoprotection down pat.

Book an appointment with my nursing team at Clinic Cutis. They have been taught how to assess & treat the majority of melasma cases. I can provide input for more challenging cases or if the diagnosis is in doubt.

My team will treat your pigment, without the hard sell. We view melasma as a medical condition, so you won’t be hammered with expensive packages.

Sydney patients can book here. 

OK, let’s say you wanna give it a go, what now? If you are insistent on microneedling as the treatment of choice based upon your research, you can ‘give it a go.’ Here are some hints to do it safely.

1. Use a max of 0.1 mm, that’s right 1/10 of a millimetre. This is the approximate thickness of your epidermis.
2. Use a stamper over a roller or a pen. With a stamper you can’t go deeper than the needle. With a pen you have the temptation of rotating that dial to go deeper, and deeper, then deeper still.
3. Make sure your sun protection is absolute. This means SPF like twice a day minimum, hats, umbrellas, tints etc…
4. Make sure your pigment cells are asleep. See a dermatologist for prescription creams & pigment inhibitors.
5. If you must, stamp once every 7 to 14 days. Stamping is designed to increase penetration of topicals. If you break the basement membrane of your skin, it is counterproductive *in the context of melasma management
6. Take photos, do a comparison. This is the only way you are going to get an objective assessment of your pigmentation.

   

A simple, cost effective way to improve pigment is as follows-

• Sunscreen twice a day. 50+ in the AM with an aerosol application in the PM
• Antioxidants in the AM (Before sunscreen). Look for vitamin C, E, ferulic acid.
• Azelaic acid in the evening. You can add a retinoid such as tretinoin 1-2 nights a week as tolerated.

Whilst DIY treatments may not clear all of your pigment, this routine is far safer than microneedling (in the context of melasma treatments).