For Life recently sought the advice of skin expert Dr Angeline Yong from Angeline Yong Dermatology, to learn melasma’s multifactorial origins, its symptoms and various triggering factors. In this article, we continue our quest for clear, flawless skin by interviewing Dr Yong once more as she explains why melasma is notoriously difficult to treat, and how she tackles this often stubborn condition in her practice.
Q: Why is melasma difficult to treat and why does it recur?
Melasma is difficult to treat because it’s a complex condition – caused by multiple factors – which requires a multi-modal treatment approach. The condition also tends to relapse because it can be triggered by many factors which are not easy to identify and control.
Q: What melasma treatments are available?
Before any treatment is recommended and prescribed, it’s important that patients recognise melasma’s recurring nature. While you can certainly manage melasma, it has no permanent cure. For this reason, I always ensure patients understand the condition, as well as its triggers and treatments, so that solutions can be tailored according to their unique lifestyle and needs.
In my practice, melasma treatments are delivered gently, as overly aggressive techniques can trigger post-inflammatory hyperpigmentation. I also tackle the condition using a combination of solutions because multi-modal approaches yield the best results. These combination treatments involve adequate sun protection (including both topical sunscreen and oral photoprotective agents containing polypodium leucotomos), topical treatments (including a 3 in 1 combination of hydroquinone, tretinoin and a steroid, alongside other topical agents such as azelaic acid, kojic acid, ascorbic acid, cysteamine and topical tranexamic acid). I may also prescribe and recommend oral tranaxemic acid, and in-clinic treatments including chemical peels and energy-based devices (such as low-fluence picosecond lasers which, in my view, are more effective at clearing melasma compared to q-switched lasers).
Q: How do these treatments work?
The first line of defense against melasma is always UV protection. This means a combination of sun-protective measures such as staying indoors as much as possible, applying broad-spectrum sunscreen of SPF50 and above, and wearing a wide-brimmed hat.
The triple combination of hydroquinone, tretinoin and a steroid (based on Klingman’s formula) is very effective in melasma management. Hydroquinone inhibits the formation of melanin. Tretinoin exfoliates the epidermis and increases the penetration of other topical treatments into the skin, while inhibiting melanin formation. Steroids are used to inhibit cell activity and melanin formation, while suppressing potential irritation caused by the hydroquinone and tretinoin.
Azelaic acid encourages cell turnover and prevents melanin synthesis.
Kojic acid is an antioxidant from several types of fungi. An effective skin-lightening alternative to hydroquinone, it works to prevent the formation of tyrosine, an amino acid needed to produce melanin.
Ascorbic acid works by inhibiting reactive oxygen species.
Cysteamine hydrochloride is another new topical agent which is naturally produced in the human body and is a degradation product of the amino acid L-cysteine. Cysteamine is also a radio protector that protects cells from the mutagenic effects of ionizing radiation via its direct scavenging effects on hydroxy radicals.
Chemical peels, using a combination of alpha and beta-hydroxy acids, such as lactic and salicylic acid slough away the outermost layer of skin, encouraging subsequent regeneration, while promoting a brighter, smoother, and less pigmented complexion.
Picosecond laser treatments are another excellent solution to reduce melasma. The lasers deliver ultra-short bursts of energy, measured in one trillionth of a second. One hundred times faster than nanosecond laser technology, picosecond lasers impact targeted skin like a shockwave which effectively shatters pigment with less damage to surrounding tissues, preventing post-inflammatory hyperpigmentation. In addition, with picosecond technology’s many wavelengths and high flexibility, it can treat a broad range of skin types, delivering more effective results with less side effects compared to traditional Q-switched lasers.
Oral tranexamic acid reduces heavy bleeding during surgery or menstruation. However, it also reduces tyrosinase activity as well as melanin production. Its mechanism of action includes blocking the conversion of plasminogen to plasmin, and blocking the binding of plasminogen to keratinocytes. Therefore, downstream effects include diminished arachidonic acid release and decreased prostaglandin and fibroblast growth factor synthesis. Since prostaglandins and fibroblast growth factor both stimulate melanin synthesis, this then leads to a reduction in melanin production. Tranexamic acid also decreases mast cells and angiogenesis. According to studies, twice daily doses of oral tranexamic acid showed improvements in melasma after four weeks. It is also given as an adjunct treatment to clinical procedures as it improves the effectiveness of laser/light therapies.
Q: Can melasma treatments take place while a patient is getting treated for underlying health conditions such as hypothyroidism? If so, will the melasma treatment be altered in any way?
I would certainly treat both conditions concurrently. If the patient has an associated thyroid disorder, I will refer the patients to an endocrinologist for further management. However, I see no harm in embarking on treatments for melasma, particularly topical agents, which do not conflict with or impair thyroid treatments that you may be taking concurrently.
Dr Yong from Angeline Yong Dermatology is an experienced and accomplished Singapore-based dermatologist accredited by the Ministry of Health. Prior to starting her own practice, Dr Angeline Yong was the founding consultant and lead of the hair transplant service of the National Skin Centre. She has in-depth experience and all-round expertise in dermatological surgery – from laser and follicular restoration, Mohs Micrographic Surgery, to other cold steel, scalpel techniques – and was the only dermatologist dual-accredited to perform both Mohs Micrographic Surgery and hair transplantation in the National Skin Centre.
Feature photo by Dreamstime