Melasma is one of the most common pigmentation problems for which patients seek treatment in Singapore. A troubling skin pigmentation, it manifests as blotchy and indistinct brown patches on the cheeks, forehead or nose. The unsightly splotches are often very noticeable and difficult to cover even with thick concealer and foundation.

Many doctors have given up on treating melasma. I’ve had patients tell me that the previous doctors and even specialist dermatologists that they had consulted had declined to treat them, advising them to just accept the way their face looks.

Why? Because they find melasma just too difficult to treat.

Worse still, some patients turn to dubious treatments which could end up causing more problems instead. Read more about potential pitfalls here.

Is there a cure for melasma?

Unfortunately, there isn’t. Does this mean that you should hide at home or resign yourself to hiding under thick layers of makeup? Of course not. Don’t give up!

Treating melasma requires a different approach to all other types of pigmentation. Melasma should be treated as a chronic medical condition, like hypertension or diabetes. Just like other chronic medical conditions, although we cannot cure melasma (for now), we can still control it well.

The key is to lighten the pigmentation and maintain it in a lightened state. It is not necessary to aggressively and totally eliminate the pigmentation, as pigmentation is being constantly produced as part of the disease process of melasma.

In fact, over-zealous treatment may lead to worsening melasma or irreversible complications.

The focus in treating melasma is on effective long term lightening and maintenance, without developing side effects or complications.

What is the latest and best way to get rid of melasma for good?

I don’t claim to have all the answers, but I have treated many melasma patients over the years. It’s one of the most common skin conditions that I encounter in my clinic.

I’ve refined my approach to melasma many, many times.

Here’s what I feel works:

Laser Treatment To Clear Built Up Pigment

Years ago, doctors used to use nanosecond q-switched NdYAG laser toning to treat melasma. Some advantages of this approach are low downtime and relatively fast and painless treatment. Laser toning can lighten melasma, however, frequent treatment is required.

Some patients even told me that doctors at other clinics told them to do laser toning daily. Over time, frequent and prolonged treatment with laser toning damages pigment-producing skin cells. This can lead to permanent unsightly complications such as the infamous white spots (hypopigmentation).

You could actually end up looking worse than just having melasma.

Another treatment you should avoid is intense pulsed light (IPL) or 'lasers' at beauty salons. Firstly, it is illegal for beauty salons to use actual lasers for skin treatment in Singapore. Secondly, beauty salons often claim to be using lasers when they are using IPL or electrocautery. These would cause far too much non-specific collateral damage with a high chance of complications like post-inflammatory hyperpigmentation, melasma flare or even scarring.

Safer Laser Toning with Pico-Lasers

Many doctors still continue to treat melasma this way but I no longer advise laser toning as the first line laser for melasma. Of course, every patient’s condition is different, and sometimes the laser toning approach is still appropriate.

When laser toning is required I would strongly recommend picosecond lasers over nanosecond lasers as the much shorter pulse duration of picosecond lasers produces less collateral damage.

This lowers the chance of complications like rebound pigmentation, post-inflammatory hyperpigmentation, melasma flare or hypopigmentation.

What I find works much better in most melasma patients:

Precision Fractional Lasers

Fractional thulium (sometimes known as the BB laser) or ruby laser are what I recommend nowadays.

What these lasers have in common is the very controlled nature of damage to the skin. Fractional lasers treat only a fraction of the skin at a time, hence the name. This enables us to clear pigmentation aggressively while still retaining normal skin tissue that acts as a healing reserve to reduce the risk of complications.

These lasers are much more specifically targeted to melasma clearance compared to other lasers.

• Thulium laser is strongly absorbed by water, hence damage is limited to the top 200 microns of the skin, where most of the pigmentation resides. Fractional thulium laser has been found to be safe and effective for melasma, with a 51% reduction in melasma score one month after three to four laser treatments and improvement over baseline even at 6 months after treatment.

• Ruby laser is much more strongly absorbed by and more selective for melanin than water or blood compared with NdYAG laser, resulting in better pigment fragmentation and less collateral damage. In published peer-reviewed research, six sessions of low dose fractional ruby laser improved melasma in 73.3% of patients, with a mean reduction of 30% in melasma score.

Thus, fractional thulium or fractional ruby lasers generally produce faster clearance and lower risks compared to laser toning. Most importantly, there is a much, much lower risk of the dreaded white spots over time, which is particularly pertinent since long term laser maintenance treatment is often necessary for melasma. They also do not need to be done as often as laser toning, hence the overall cost works out to about the same or even less.

Fractional thulium and ruby lasers are far less common in Singapore medical aesthetics clinics, unlike q-switched NdYAG lasers which are available almost everywhere. Like all lasers, over-aggressive settings can worsen melasma.

Melasma is a multifactorial chronic disease process. While most of my patients respond to fractional ruby, fractional thulium or picosecond laser, combination laser therapy (such as adding on vascular lasers 0 see below) can sometimes be required. Make sure your doctor has a wide range of options to treat your melasma and adequate experience treating melasma with each laser.

Medications and Supplements to Suppress Melasma Activity

Melasma is a condition where oxidative stress stimulates hyper-functioning melanin-producing cells to produce excess pigmentation. This is a continuous, ongoing process that medical research has not yet found a permanent cure for.

Lasers get rid of the accumulated pigmentation. However, without controlling the excessive stimulation and production of pigmentation in melasma, results will be limited. The pigmentation that was eliminated by the lasers will quickly be replaced by fresh new melanin produced by the over-active melasma afflicted skin.

Topical (applied) and oral therapies are absolutely essential to control melasma activity alongside appropriate laser therapy.

Sun Protection

Melasma can be caused or worsened by not only the sun's rays but also heat and visible light. Therefore liberal and frequent usage of a broad spectrum sunscreen is absolutely essential. For melasma patients, tinted sunscreens with at least SPF50 and PA +++ are recommended.

Physical or mineral sunscreens are preferred in melasma patients. These reflect or disperse UVA and UVB rays. Physical sunscreens are usually much gentler and less likely to cause irritation, allergic reactions or convert light to heat energy. Thus they are less likely to trigger melasma.

Oral therapy

Oral medications and dietary supplements are effective and proven in clinical research to help melasma. These include:

• Tranexamic acid
  • a derivative of the amino acid lysine
  • decreases arachidonic acid generation, reducing melanocyte-stimulating hormone (MSH) and pigment production
  • may also decrease VEGF and endothelin-1, which may be responsible for increasing vascularity in melasma
  • studies found improvements in melasma starting after one to two months in 90 to 96% of patients
• Polypodium leucotomos extract (PLE) (such as Heliocare Oral Ultra)
  • a fern from the Polypodiaceae family, native to Central and South America
  • Polypodium leucotomos aqueous extract is a potent antioxidant with demonstrated photo- and immunoprotective activities against ultraviolet (UV) A and UVB radiation
  • Studies have found it can significantly reduce the severity of sunburn, decrease the risk of UV radiation-induced skin cancer, and prevent skin ageing
  • Commonly used as an ‘oral sunblock’
  • Studies in melasma patients showed that addition of PLE lead to greater and faster improvement of melasma
• Procyanidin
  • A flavonoid, polyphenol phytochemical extracted from pine bark or grape seed, with antioxidant and anti‐inflammatory properties
  • studies showed significant melasma improvement (up to 80%) starting after 1 month
  • in a Japanese study, oral proanthocyanidin‐rich grape extract for 6 months improved pigmentation in 83%
• Colourless carotenoids (such as Crystal Tomato)
  • carotenoids concentrate in the skin and work by scavenging reactive oxygen species produced during photo-oxidative processes induced by UV damage
  • a randomized clinical study demonstrated that 800 mg of carotenoids daily produced greater improvements in melasma scores

These ingredients have been studied in randomised controlled trials for safety and efficacy in melasma.

In my experience, oral therapy works very well to control pigment production, but it is best to use various oral medications and dietary supplements in combination as they work synergistically to suppress melasma activity at various steps of the disease process.

Topical therapy

A wide variety of topical treatments have been used for melasma. Hydroquinone has been the gold standard. Others agents include azelaic acid, kojic acid, retinoids, niacinamide, corticosteroids, hydroxy acids such as salicylic and glycolic acid, arbutin, resveratrol, resorcinol, tranexamic acid, cysteamine and chemical peels.

These work by reducing melanin production or accelerating melanin removal. As with most things, combination treatment with multiple agents produces a better response. This also allows usage of lower concentrations, reducing side effects in the short and long term.

Personally, I find that none of the commercial products have all of the necessary ingredients, so I use custom-designed creams formulated in a compounding pharmacy. This gives the best control over the effectiveness and tolerability of the therapy.

Recalcitrant Cases May Need Combination with Adjunct Treatments

I’ve encountered my fair share of recalcitrant melasma where the pigmentation either fails to respond to laser or relapses quickly.

Firstly, it is important to ensure that oral and topical medication is being used regularly and correctly, as well as proper sun protection.

Melasma is a heterogeneous spectrum of disease - What works for most patients may not work for you, and your melasma may, in fact, respond better to another therapy. In recalcitrant or difficult cases, it is very helpful to have a wide range of laser treatments available, such as picosecond q-switched laser, fractional lasers, etc.

Studies suggest that melasma may have a vascular component to its pathogenesis. The number and size of blood vessels are significantly greater in areas of melasma compared with normal perilesional skin. Overexpression of vascular endothelial growth factor (VEGF) is seen in melasma skin.

Vascular-targeted therapies to help improve clearance and decrease recurrence. Auxilliary treatments such as vascular lasers (e.g. Quanta 585, pulsed dye laser, yellow lasers) or fractional microneedling radiofrequency (e.g. Sylfirm) can help to suppress the melasma activity as an adjunct to laser treatment, particularly in stubborn cases.

Conclusion

Melasma is difficult, but not impossible to manage long-term. Combination treatment is a cornerstone of melasma management. Appropriate treatment can produce dramatic improvements and satisfied patients. Many of these patients have become my friends over the years.

Don’t be afraid to seek treatment!

I really emphasize with melasma sufferers and would like to offer help wherever possible.

Please feel free to drop me a message if you need any clarifications or a second opinion. I’ll try my best to help!

References

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