The truth about Melasma…
Many dermatologists won’t treat it…
Because they fear making the melasma worse… resulting in a patient that is even more unhappy than when they first walked through the office door.
Many dermatologists will only go as far as prescribing a hydroquinone “bleaching” cream… which typically will lighten the skin until you stop using it, only to have the melasma come right back. Therefore, if you have a melasma, and you are looking for a physician who will treat it, you had better read this article carefully.
WHAT EXACTLY IS MELASMA?
Excessive amounts of melanin produced in irregular darker patches of skin, occurring primarily on the face. This befalls primarily women of mid-color skin, who are Hispanic, Asian, Hindu-Pakistani (Type-4 skin). Why do these skin types get melasma? The theory is simple.
- The melanocytes of very pale skin are simply resistant to stimulation. That is why they don’t tan, or spot, or get melasma. In the sun they simply burn.
- The skin of black people is so dark, that even if their melanocytes are producing extra melanin, we can’t see it on the background of their already dark skin.
- However, the unfortunate group in the middle, whose base color is light-to-medium, who are very sun-sensitive and who tan fast and dark, and whose melanocytes can be easily provoked to produce excess melanin which is easy to see due to their relatively light background color. We affectionately call our patients in this category, the “unlucky ducklings in the middle”.
First, the basics. What is melanin, and what is it for?
On the border between the epidermis (the surface layer of your skin) and the thicker dermis beneath it, are located cells called melanocytes that make the natural pigment in your skin called melanin. Melanin is absorbed into epithelial cells as they migrate towards the surface of your epidermis. Upon reaching the surface the epithelial cells die and comprise a thick layer of dead epithelial cells – like a crust filled with melanin – that lie at the very top (surface) of your skin. In this way, both layers of your epithelium – the dead layer and live layer – are filled with melanin… which is how your body protects itself against excessive sun damage.
How does melanin protect us from sun damage?
Melanin in your epidermis absorbs sun light at the surface and blocks solar radiation from penetrating deeper into the skin. As you probably know, sun light is in fact a form of solar radiation, and though all life on planet earth is dependent on the sun’s energy, the fact is that sun radiation is very powerful, and can cause much damage to anything that is exposed to too much of it. That is why people with genetic programing originating from regions located in the Sahara Desert, such as Ethiopia or Sudan, have extremely dark black skin. Whereas people with genetic programing from northern regions with very little sun, tend to be extremely pale.
Bottom line, human physiology is designed with a mechanism for sun protection provided by melanin made in our skin by melanocytes. That is why you tan! For example, imagine that you go on vacation to the beaches of Hawaii, where suddenly you are exposed to way more sun than your skin is accustomed to. Instantly your melanocytes become stimulated by the extra sun, and immediately produce extra melanin in your skin to protect you. Thus, your sun-tan is your natural sun-block.
MELANIN – OUR NATURAL SUNBLOCK
Overall, this also means that naturally darker skin is better protected from sun damage than lighter skin.
For instance, take 3 women 50-years old with the exact same life style and sun exposure; the first with black skin; the second with Hispanic or Asian skin; and the third with Caucasian skin. The black woman will have the healthiest skin, the Hispanic/Asian woman will be in second place, and the unfortunate white woman will be a distant last place, with the most damaged skin, wrinkled, spotted, sun damaged, and most likely to have skin cancer. This is especially true of very pale people, who can barely tan if at all, and who quickly burn with but a few short minutes in the sun. In fact, for some, excessive sun exposure can be literally fatal.
More severe cases (sun poisoning) are complicated by severe skin burning and blistering, massive fluid loss (dehydration), electrolyte imbalance, and possibly infection. With too much exposure, severe untreated sunburn can cause shock (poor circulation to vital organs) and even death. See: Sunburn (Sun Poisoning): Facts on Relief and Remedies
Ever heard the saying: “Black don’t crack”? Now you know why that saying is accurate. However, for those with darker skin that are reading this, your darker skin does not make you immune to sun damage. Though it will take more sun exposure to make your skin burn, pushed too far it will burn, and yes, your skin can also develop skin cancer.
WHAT CAUSES MELASMA?
Nobody really knows exactly what causes melasma. Here are the possibilities:
There is a definite correlation between hormonal fluctuations and melasma, such as during pregnancy when the dreaded “mask of pregnancy” appears. Furthermore, the skin of some women is so sensitive to hormonal fluctuations that going on birth-control medication, stopping birth-control medication or even changing brands of birth-control medication can provoke a melasma. Bottom line, in some women of mid-color skin, melanocytes are sensitive to hormones.
- But why then do only some areas of the face get darker and not others?
- Why not the entire face, or any other sun exposed skin of the body?
- Why are many women who are not experiencing any measurable hormonal fluctuations still plagued with melasma?
Once again, nobody really knows.
B. Irritation to the skin – Post Inflammatory Hyperpigmentation (PIH)
Irritation to the skin can cause excessive pigmentation in mid-color skin of both men and women. For instance, for women who wax, thread or pluck hair on their upper lip, after years of this irritation, the traumatized melanocytes become hyperactive and cause localized hyper-pigmentation. This is classified as “post inflammatory hyperpigmentation” (PIH) and though it may look like melasma, it technically is not.
Another common example of PIH, is the pigmentation due to cystic acne… especially if you have aggravated the situation by picking at it. Even after the cyst has resolved, the dark PIH spot may linger for weeks, even months, depending on the type of skin you have. Once again, men and women who have mid-color skin… of “unlucky duckling in the middle” are most susceptible to PIH.
What is true however, is that for some, what started as localized PIH may have slowly spread and become what presents as a melasma. It is very important to discern this during the initial consultation.
C. Excessive sun exposure.
As in B. above, sun burn is a significant irritation to the skin, and over time can provoke a melasma in mid-color skin types of both men and women.
Question: Given all the things we don’t know, can Melasma be successfully treated?!
Answer: Yes, Melasma can be successfully, treated… but first we must distinguish between a stable melasma and an UN-stable melasma
STABLE VS UN-STABLE MELASMA
Stable Melasma: Simply stated, a stable melasma is one that does not change much from day to day or week to week. It stays pretty much the same. Additionally, a stable melasma does NOT easily flare up when exposed to a few minutes of sun.
To understand this better, imagine a pregnant woman, who during her pregnancy develops a melasma. Obviously, the hormonal fluctuations of pregnancy provoked her melasma. Once her baby is born and her hormones return to normal, the melasma tends to resolve on its own as the over stimulated melanocytes calm down. However, in some cases the melasma persists, but is stable. Simply understood, given that the underlying hormonal fluctuations that caused the melasma have resolved, the melasma is no longer “motivated” to grow or spread. It seems therefore that the melanocytes that were over-producing melanin during the pregnancy are now “stuck” at this higher level of melanin production.
A good analogy is a house with many rooms, each of which has a thermostat set at a perfect temperature of 72 degrees. But then, something happens to the house, and the thermostat of one room is upset and stuck at 80 degrees, and thus, is always hotter than all the other rooms. Essentially, in a stable melasma, the melanocytes in a certain area of the skin are upset and stuck at a higher level of melanin production.
This kind of stable melasma has a very good chance of being successfully treated, as I will describe later in this article on the treatment of melasma.
Un-stable melasma: Simply stated, an Un-stable melasma is constantly shifting, is easily provoked to getting darker, and is extremely sensitive to any sun exposure. Even exposure to heat, on a hot day or a hot-tub can make the melasma flare up. Simply explained, there is some underlying cause that is making this unfortunate woman’s melanocytes hypersensitive and hyperreactive.
In an un-stable melasma, even when the extra melanin is successfully removed from a woman’s skin, it tends to come back in a matter of weeks, even days… because some mysterious underlying condition is constantly instigating the melanocytes to produce extra melanin.
About the Authors
Doctors Alice Pien, MD and Asher Milgrom, Phd are established pioneers in the fields of Regenerative Medicine and Skincare. Their expertise ranges from advanced laser systems to stem cell medicine. Their medical education and advanced certifications span from medical schools of NY State University, the University of Chicago, to John Hopkins, Harvard and UCLA. They approach medicine with the clinical expertise of over 85,000 successful treatments over the past 20 years and significant scientific research resulting in proprietary protocols that they customize for each individual patient.