Melasma Treatment Singapore
What is Melasma?
Melasma is a common skin condition where symmetrical brown patches appear mostly on the facial sun exposed areas in women of Asian ethnicity. Multiple factors are believed to be implicated in the formation of this prevalent hyperpigmentation disorder. Melasma, also known as Cholasma, the mask of pregnancy can be seen right after childbirth. Although common, melasma is often chronic and can worsen from time to time. A successful melasma treatment approach seeks to minimise trigger factors, protect the skin and maintenance therapy to reduce relapse.
How Common Is It?
The incidence of melasma is increasing worldwide. Up to 40% of women in Southeast Asia may suffer from melasma. However, true incidences are related to geographical location, ethnicity and amount of UV exposure one receives. Even though it frequently occurs during the reproductive years, it is not uncommon for many women to present with melasma later in life.
Despite women making up overwhelmingly 90% of the cases of melasma, it can affect men with significant impact on their quality of life.
In general, melasma fades after menopause, but can persists even in non-facial areas.
What causes Melasma?
The exact cause of melasma is unknown. The interaction of sun exposure, hormonal influence and oxidate stress in genetically predisposed individuals are thought to trigger off melasma.
UV light is thought to induce reative oxygen species that stimulates melanin synthesis. Recent studies have also shown that visible light can also induce hyperpigmentation. It is of no surprise then that individuals with melasma often notice their pigmentation being exacerbated by light exposure.
A genetic predisposition to melasma is involved in about 50% of cases. This is especially so with inidividuals with darker skin types. The genes contributing to melasma may not only be involved in regulating pigmentation, but also inflammatory, hormonal and vascular responses.
Hormones play an important role in melasma. While melasma affects women in much greater proportion to men, it is often triggered by pregnancy, oral contraceptive pills and hormomal therapies.
Why Treat Melasma?
The impact melasma can have on your quality of life cannot be underestimated. Being visible, melasma may be difficult to conceal even with make up. Studies have shown that having melasma leads to reduced self-esteem, anxiety and depression.
What Does It Look Like?
Melasma tends to present as flat symmetrical hyperpigmented patches. It is found mainly on the central portion of the face, cheeks and jawline. It is not common for melasma to extend to extra-facial areas such as the chest and limbs. The edges of melasma are often irregular.
In our experience, many individuals may have a mixture of hyperpigmentation and other dermatological conditions in addition to melasma. These may include freckles, solar lentigenes, seborrheoic keratoses and skin tags.
What Are The Different Types Of Melasma?
Melasma may affect all layers of the skin. When pigmentation affects only the upper outer layer of the skin, it is known as epidermal melasma. When the pigments are lodged more deeply into the dermis, it is then known as dermal melasma. Mixed melasma has both epidermal and dermal components. It is important to differentiate the different types of melasma during your consultation as it will give a guide to the best treatment option.
- Epidermal melasma
- Dermal melasma
- Mixed melasma
How Is It Diagnosed?
Melasma is diagnosed based on the history, distribution and clinical examination of your skin.
A Wood’s lamp is used to examine the distribution and severity of the condition. This serves as a guide to determine how deep the melasma is, and the presence of other pigmented skin conditions, such as freckles and sun spots.
The Melasma Area and Severity Index (MASI) can be used to assess the severity and extent of your melasma. This measure of assessment takes into account the area involved, darkness and homogeneity of the areas. The higher the score, the more severe the symptoms. However this remains a subjective assessment tool, and serial clinical photography remains a practical way to assess response to treatment.
Of course, while we have tools to assess the physical symptoms, we must not underestimate the psychological impact of the skin condition. Often in Asian cultures, individuals may feel self conscious, embarrassed and feel the condition to be ‘unsightly’.
How can I reduce It?
Although Melasma is considered a chronic pigmentary skin condition, there are steps that you can take to reduce the worsening of your symptoms.
- Elimate trigger factors such as direct sun exposure, sunbeds and sun tanning.
- Sun protection: Melasma is very sun sensitive. Use a Sunblock of at least SPF 30-50 and PA+++ regularly
- Cosmetic Camouflage
You will be able to find more resources here.
When it comes to the treatment on melasma, no single treatment modality will yield the best results. A combination approach taking into account the severity of the melasma, the type of melasma and your skin type will better improve the appearance of your melasma.
Melasma treatments include:
- Topicals lightening agents
- Oral medications e.g. tranexamic acid
- Chemical Peels – induces epidermal renewal
- Energy based devices and Lasers
Topical Therapy for Melasma
Combination topical therapy that reduces melanin production, increases skin cell turnover and reduces the inflammatory component is superior to monotherapy. During consultation, Dr Ng will advise on the type of topical treatment that is suitable for your skin.
The first line treatment of Melasma involves using a triple combination of products, which contains Hydroquinone, Tretinoin and a steroid. Hydroquinone is a skin lightening agent that reduces melanin synthesis by inhibiting the enzyme involved in the process. The tretinoin (a retinoid, or Vitamin A based cream) enhances melanin elimination by increasing cell turnover and reducing melanocytic activity. The steroid cream, which is mild in potency aims to reduce inflammation. This triple combination regime is reported to improve Melasma symptoms in 60-80% of individuals treated, and visible improvement is noticeable at 8 weeks.
Other Topical formulations thought to be beneficial may include:
- Azelaic acid
- Kojic acid
- Tranexamic acid
- Ascorbic acid (Vitamin C)
Oral Therapy for Melasma
- Tranexamic Acid is the best studied and most common off-label oral treatment for melasma. It works by reducing the enzymes involved in melanin formation. When combined with topical therapy, improvements can be observed earlier. However, studies have shown that while it can effectively reduce melasma, relapse is common after halting therapy.
- Pycnogenol: Has potent antioxidant and anti-inflammatory properties
- Polypodium leucatomos
Laser Melasma Treatment
For more than a decade, various laser systems have been used in their attempt to treat melasma. Various studies and methods of lasering have not shown which laser system to be the most optimal in the treatment for melasma. This is not surprising as the cause of melasma is multifactorial, and targeting only the pigmentation component is not ideal.
Lasers work by the principle of selective thermolysis. Ablative laser systems such as the CO2 and Er:YAG laser which mainly target water within the skin are deemed too harsh with resultant increased incidences of post-inflammatory hyperpigmentation.
On the other hand, non-ablative lasers such as the Q-Switched and Pico-second laser selectively target the melanin and is safer in individuals with darker skin type. Studies have shown that gentle non-ablative laser treatments with topical lightening creams gives better results compared to monotherapy. However, lasers are not without their side effects.
Melasma can still recur despite laser treatment, may result in post-inflammatory hyperpigmentation (dark spots) and mottled hypopigmentation (white spots). From experience, Dr Ng believes that while laser as a treatment can be offered, it must not be relied on solely to treat melasma. Their use must be judicious.
A new approach that has gained traction is the creation of microchannels within the skin to facilitate the absorption of topical therapy. In addition, the wounds created by microneedling induces collagen and elastin, and helps in melanin elimination through the skin. Topical therapies inclide Vitamin C, platelet rish plasma and various depigmenting agents.
Microneedling is a promising procedure that is safe but results are variable, hence more studies are required before widespread adoption in clinical practice.
Our Customized Approach to Melasma Treatment
Melasma remains a challenging condition to treat because it is chronic, relapses are common and is associated with psychosocial impairment. Although there is no cure for melasma, treatment strategies help to control and prevent worsening of the condition.
With the current body of knowledge and experience, a combination and individualised approach is taken. Successful treatment takes into account the type of melasma, severity and treatment options to manage it.
During consultation and examination, you will be advised on the best melasma treatment plan to help you control this common condition.
- Ogbechie-Godec, O.A., Elbuluk, N. Melasma: an Up-to-Date Comprehensive Review. Dermatol Ther (Heidelb) 7, 305–318 (2017). https://doi.org/10.1007/s13555-017-0194-1
- Lee MC, Lin YF, Hu S, Huang YL, Chang SL, Cheng CY, et al. A split-face study: comparison of picosecond alexandrite laser and Q-switched Nd:YAG laser in the treatment of melasma in Asians. Lasers Med Sci 2018;33:1733-8.
- Choi, Y.-J., Nam, J.-H., Kim, J.Y., Min, J.H., Park, K.Y., Ko, E.J., Kim, B.J. and Kim, W.-S. (2017), Efficacy and safety of a novel picosecond laser using combination of 1 064 and 595 nm on patients with melasma: A prospective, randomized, multicenter, split-face, 2% hydroquinone cream-controlled clinical trial. Lasers Surg. Med., 49: 899-907. https://doi.org/10.1002/lsm.22735
- Cassiano DP, Espósito AC, da Silva CN, Lima PB, Dias JA, Hassun K, Miot LD, Miot HA, Bagatin E. Update on Melasma—Part II: Treatment. Dermatology and Therapy. 2022 Sep;12(9):1989-2012.