The long-drawn battle against melasma

Dr Teresita Ferrariz, Board of Director, International Society for Dermatologic Surgery (ISDS) Philippines, veers the focus of melasma treatment to PRP while expounding the resistance that practitioners face while treating melasma.

Dr Ferrariz sums up the principles of melasma therapy as:

● Protection from sun exposure

● Inhibition of tyrosinase activity

● Removal of melanin

● Destruction or disruption of melanin granules

The first line of therapy for treating melasma includes topical meds such as Kligman’s formula with 4% BI cram at HS x 3 months (tapered off depending on the response), Vitamin C serum and Hydrocortisone 1% cream for two weeks. This is followed by oral medication including polypodium leucotomos fern extract, glutathione lozenge OD-BID, ascorbic acid 1000 mg TID and tranexamic acid 250 mg BID for two to eight weeks. Other products include azelaic acid, liquorice cream, kojic acid, tranexamic acid gel and vitamin E. The second line of therapy comprises a chemical peel every three months for a year (TCA 20% and Glycolic 70%) and mechanical peels such as diamond and platinum peels.

The third line of therapy for Dr Ferrariz is PRP plus, the Facial Oxygen Infusion. Platelets found in PRP contain a huge reservoir of bioactive PR including growth factor and signalling PR that are vital to initiate and accelerate tissue repair and regeneration. Plasma contains many factors essential for cell survival including nutrients, vitamins, hormones, electrolytes PR and growth factors.

Dr Ferrariz explains, “According to Dr Jeremy Magalon, a French pharmacologist, in a recent IMCAS webinar on PRP and regenerative medicine highlighted that the scientific proof of bone and soft tissue healing enhancement has been shown using PRP with 1,000,000 platelets / ul in a 5 ml volume of plasma and which is the working definition of PRP today.”

Elaborating on how PRP works, she says, “On activation, the intracellular storage pool of growth factors fuse with the platelet cell membrane and activate the secretory proteins to a bioactive state. These growth factors bind the transmembrane receptors on the target cells (epidermal cells, mesenchymal stem cells, fibroblasts), inducing an internal signal transduction pathway thereby increasing expression of various gene sequences in cells like cell proliferation, collagen synthesis and anti-apoptosis.”

Ways to activate PRP:

● Pinpoint bleeding in dermaroller

● Thrombin

● Derma collagen and inflammation: Collagen is a natural activator of PRP thus when injected in the soft tissue, it does not need to be exogenously activated.

● Radio frequency: It can activate platelets and promote collagenesis. It affects the deeper tissue plane whereas PRP is injected superficially. There may be potential synergy for multiplane skin rejuvenation.

Her technique involves:

● Intradermal injection

● Frequency: Four sessions x two to four weeks interval

● Repeat after six months

● Repeat after one year

● Start with the lower eyelid area with 1 cm spacing for periorbital rejuvenation targeting pigmentation and fine lines.

● Irrespective of the method of activation, the growth factors start within 10 minutes of the injection process and more than 95 per cent of secretion is completed within an hour, so PRP must be applied within 10 minutes of activation.

Dr Ferrariz herself used to suffer from melasma and has treated it with PRP and combination of vitamin C serum, anti-ageing serum, glycolic acid peel, sunscreen of SPF 50 and intraceutical oxygen infusion.

How does PRP work on melasma?

Autologous PRP releases growth factors - cytokines and chemokines - that promote self-proliferation and differentiation as well as a mechanism to improve pigmentation. One of these is the inhibition of tyrosinase by transforming growth factor beta-1, which reduces melanin synthesis. Moreover, the epidermal growth factor lowers melanin production in melanocytes by inhibiting PGE2 expression and tyrosinase activity.

The Hyperbaric Oxygen Therapy involves an intraceutical infusion application method that uses Hyperbaric Oxygen to promote the delivery of intraceuticals serums to the skin. The infuser creates a hyperbaric pressure bubble to initiate osmotic hydration and activates delivery. This is followed by an infusion of opulence serum. It also has citrus unshiu peel extract, a type of Japanese mandarin, which breaks up surface melanin build up. The oxygen also eradicates the free radicals.

Dr Ferrariz asserts, “PRP is a good alternative in the treatment of long standing melasma but it is not a standalone treatment. For optimal results, it may be combined with other treatment modalities like topicals (sunscreen, bleaching agents), microneedling, chemical peeling and lasers and oral medication. Due to limited studies on clinical efficacy and safety, further studies are required to investigate the mechanism of action behind the therapeutic effects of PRP and its long term safety.”

To conclude, she points out that since PRP uses the body’s own natural platelets, there is no risk of allergic reactions. Natural collagen is formed in response to the presence of the activated platelets. PRP can be used to enhance several procedures for faster and improved healing. Smoking and alcohol intake diminishes stem cell release while anti-inflammatory drugs are to be restricted for about one to two weeks.

“For optimal results, PRP may be combined with other treatment modalities like topicals (sunscreen, bleaching agents), microneedling, chemical peeling and lasers and oral medication.”