Treating melasma the Indian way

Indian dermatologists have vast knowledge and experience in treating melasma on skin type 4-5. It is therefore important to understand their perspective and know the challenges that they face. Melasma in itself is a complicated condition, quite rampant and recurring. This makes the course of treatments that practitioners have tried and tested more relevant.

Dr Apratim Goel

Dr Jagdish Sakhiya

Dr Chiranjiv Chhabra

Dr Rajesh Nair

Dr Falguni Shah

We roped in Dr Apratim Goel, Medical Director & Founder, Cutis Skin Solution, Mumbai; Dr Jagdish Sakhiya, Director, Sakhiya Skin Clinic, Mumbai; Dr Chiranjiv Chhabra, Dermatologist and Director-in-Chief, Alive Wellness Clinic, New Delhi; Dr Rajesh Nair, Founder, SkinCare Speciality Centre, Thiruvananthapuram; and Dr Falguni Shah, Dermatologist, Cosmetologist, and Founder, Radiance Skin Clinic, Mumbai, to give their expert views on the subject.

Dr Goel points out to a macro view of hyperpigmentation as it is one of the primary challenges faced by cosmetic practitioners in India. “Pigmentation occurs in various forms such as PIH, periorbital, perioral, post acne, melasma, freckles, and amyloidosis, and these can co-occur, too. Plus there is the demand from Indian patients to become fair.”

She also pointed out the following factors that affect the way melasma and hyperpigmentation are treated in India:

● Multiple aetiology

● Target chromophore melanin at various depths and locations

● UV stimulation is an important and unavoidable factor

● Monotherapy usually does not help

● Treatment options are many and confusing

● Lot of variation in response to treatment

● No universal treatment guidelines

● It is a cosmetically distressing problem

Technology to the rescue

Dr Chhabra, who has used practically every technology to treat hyperpigmentation at her clinic, uses a combination of laser and hyaluronic acid skin boosters in the form of mesotherapy to treat melasma. She does not prefer chemical peels for melasma. She uses a combination of long pulse Nd:YAG, Q-switch and fractional non-ablative 1440 1550 lasers in this progressive order. “After the inflammation has subsided, the exfoliation is complete and the skin has healed, in about three to four weeks, I call the patient again for hyaluronic acid skin boosters,” she explains.

While using the boosters on the entire face, Dr Chhabra has discovered that they have a desirable effect on melasma patches. She now uses the 1ml HA booster syringe on the melasma patch to improve the effects of the laser treatment. The laser and booster sessions are repeated every month for three months. “Earlier I used Belotero boosters but now I use Restylane Vital and Juvéderm Volite, which I give either very deep dermally or subcutaneously.” She adds,

“Melasma is basically inflammation turned into pigmentation so we need a tool that will objectively reduce the inflammation. We cannot put patients on steroids for a longer period and vascular lasers work on the outcome of inflammation rather than the inflammation itself. So, we need some good molecules to address this issue and something the patient does not get addicted to.”

She also points out that using the Q-switch Nd:YAG laser alone did not give the desired results as the laser worked on the postinflammation extracellular pigmentation and resulted in hypopigmentation when used over a long period of time. The long pulse Nd:YAG laser was much safer to use in the long run with good results.

Diagnose it right

Dr Nair opines that there is a wide basket of treatments available for melasma but the choice largely depends on the type of melasma that we are dealing with. For melasma patches, he prefers spot TCA peel with 20-25% followed by multiple sessions of lasers. “For patients with extensive lesions on a large part of their face, I start with erbium YAG laser, which improves the skin’s texture, and follow it with Q-switch Nd:YAG laser.” He further states, “A particular combination of treatment does not always work on all patients. My favourite combination would be a TCA peel and laser. As the patients are generally frustrated with pigmentation, the TCA peel gives them instant skin lightening.”

Speaking about male melasma, Dr Nair expounds that it is difficult to treat because male patients do not follow protocol and come for follow-up sessions. They do not apply sunscreen although they are more exposed to UV radiation, plus their melasma is quite thick and stubborn. I do not use TCA peels much on men as photo protection becomes a problem.”

“My top treatment choice would be Q-switch laser with PTP mode followed by intradermal hyaluronic acid,” says Dr Shah. “But I do not use the cross link at all. I use the non-cross link filler just the way it comes, without diluting it. This combination works well when the pigmentation is diffused and not on concentrated melasma.”

Dr Chhabra exemplifies that she had used PRP for facial rejuvenation for her patients but failed to notice any marked improvement in their melasma. However, she also considered the fact that it could be due to the quality of tubes and PRP used.

Dr Sakhiya builds up on this premise: “For PRP to work, we need some trauma for the collagen fibre to stimulate the platelet.” He suggested a triple combination of Q-switch Nd:YAG laser, PRP and HA boosters. Since crosslink molecule is expensive and sometimes the practitioner or the patient does not want to invest in it, there are other readymade meso cocktails available such as Mesohyl, which is a viscous solution. Also, if you are using 585 filter on a good IPL, it will accelerate the process. “In my practice, we use IPL with lactic peel or Q-switch with lactic peel and PRP,” he affirmed.

We probed our experts further on other add-on treatments for melasma and here are their opinions:

1. IV Glutathione: Does not really work on melasma but definitely gives a feel good factor to the patient.

2. Intralesional tranexamic acid mesotherapy: Used in diluted dosages but no analysis is done to ascertain its impact on melasma.

3. LED light panels: Help in reducing inflammation.

4. HIFU: Shows promising results.

The treatment for melasma is multi-faceted and progressive, and is largely dependent on the type of melasma and its triggers.

Our experts have laid a lot of emphasis on correct in-depth consultation and phased out treatment protocol, considering the recurring nature of the condition. However, in their daily practice, they have successfully treated melasma with a combination of treatments, and they are willing to try newer therapies and combinations.

We, at Aesthetic Medicine India, will continue to bring you updates on melasma and learnings from the personal experiences of the country’s leading cosmetic practitioners.